Basic Information
| Provider Information | |||||||||
| NPI: | 1316944598 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACK HAWK-GRUNDY MENTAL HEALTH CENTER INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3251 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192342893 | ||||||||
| FaxNumber: | 3192340354 | ||||||||
| Practice Location | |||||||||
| Address1: | 3251 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192342893 | ||||||||
| FaxNumber: | 3192340354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 06/19/2017 | ||||||||
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| AuthorizedOfficialLastName: | EACHUS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3192342893 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LISW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 0074435 | 05 | IA | MEDICAID |