Basic Information
| Provider Information | |||||||||
| NPI: | 1417086638 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAHASKA COUNTY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NEW DIRECTIONS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1229 C AVE E | ||||||||
| Address2: | |||||||||
| City: | OSKALOOSA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525774246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416723159 | ||||||||
| FaxNumber: | 6416723259 | ||||||||
| Practice Location | |||||||||
| Address1: | 1229 C AVE E | ||||||||
| Address2: | |||||||||
| City: | OSKALOOSA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525774246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416723159 | ||||||||
| FaxNumber: | 6416723259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHRISTENSEN | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMIN, CEO | ||||||||
| AuthorizedOfficialTelephone: | 6416723100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 01101 | IA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 01101 | 01 | IA | LICENSE | OTHER |