Basic Information
| Provider Information | |||||||||
| NPI: | 1912378480 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIOUXLAND COMMUNITY HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SIOUXLAND COMMUNITY HEALTH CENTER OF NEBRASKA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 NEBRASKA ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511051436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122522477 | ||||||||
| FaxNumber: | 7122241895 | ||||||||
| Practice Location | |||||||||
| Address1: | 3410 FUTURES DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH SIOUX CITY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687763917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122522477 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2015 | ||||||||
| LastUpdateDate: | 06/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | JAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7122021002 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0092080 | 05 | IA | MEDICAID | 281840 | 01 | IA | MEDICARE OSCAR/CERTIFICATION | OTHER |