Basic Information
| Provider Information | |||||||||
| NPI: | 1578535548 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAWKEYE CARE CENTER OF SPIRIT LAKE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HAWKEYE CARE CENTER SPIRIT LAKE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1912 ZENITH AVE | ||||||||
| Address2: | SUITE 2526 | ||||||||
| City: | SPIRIT LAKE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 513601000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7127591321 | ||||||||
| FaxNumber: | 7127591322 | ||||||||
| Practice Location | |||||||||
| Address1: | 1912 ZENITH AVE | ||||||||
| Address2: | |||||||||
| City: | SPIRIT LAKE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 51360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123363300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 09/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | DOUG | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5152230173 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 300353 | IA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0809475 | 05 | IA | MEDICAID |