Basic Information
Provider Information | |||||||||
NPI: | 1740246883 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HAWKEYE CARE CENTER OF CRESCO LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HAWKEYE CARE CENTER CRESCO | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 701 VERNON RD | ||||||||
Address2: |   | ||||||||
City: | CRESCO | ||||||||
State: | IA | ||||||||
PostalCode: | 521361944 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5635473580 | ||||||||
FaxNumber: | 5635473532 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2006 | ||||||||
LastUpdateDate: | 09/01/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JOHNSON | ||||||||
AuthorizedOfficialFirstName: | DOUG | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 5152230173 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 450905 | IA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 0809467 | 05 | IA |   | MEDICAID |