Basic Information
| Provider Information | |||||||||
| NPI: | 1609862887 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHENANDOAH MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ELM HEIGHTS CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 PERSHING AVE | ||||||||
| Address2: | |||||||||
| City: | SHENANDOAH | ||||||||
| State: | IA | ||||||||
| PostalCode: | 516012355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122464627 | ||||||||
| FaxNumber: | 7122467357 | ||||||||
| Practice Location | |||||||||
| Address1: | 1203 S ELM ST | ||||||||
| Address2: | |||||||||
| City: | SHENANDOAH | ||||||||
| State: | IA | ||||||||
| PostalCode: | 516012221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122464627 | ||||||||
| FaxNumber: | 7122467357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 08/04/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEWILD | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7122464627 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 730860 | IA | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 730860 | IA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0806505 | 05 | IA | MEDICAID |