Basic Information
| Provider Information | |||||||||
| NPI: | 1235225699 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IOWA JEWISH SENIOR LIFE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 POLK BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503122225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152555433 | ||||||||
| FaxNumber: | 5152778898 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 POLK BLVD | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503122225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152555433 | ||||||||
| FaxNumber: | 5152778898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BLEND | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5152555433 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | S384 | IA | X | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | S384 | IA | X | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0802025 | 05 | IA | MEDICAID |