Basic Information
| Provider Information | |||||||||
| NPI: | 1497714224 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BETTENDORF NURSING HOME COMPANY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BETTENDORF HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1026 | ||||||||
| Address2: | |||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527220018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633327463 | ||||||||
| FaxNumber: | 5633323656 | ||||||||
| Practice Location | |||||||||
| Address1: | 2730 CROW CREEK RD | ||||||||
| Address2: | |||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527222066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633327463 | ||||||||
| FaxNumber: | 5633323656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 05/16/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHENSVOLD | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3193628916 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 820880 | IA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0809178 | 05 | IA | MEDICAID | 16D0387557 | 01 | IA | CLIA | OTHER |