MEDICARE: CHILDSERVE HOMES INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility	771147	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043352875
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDSERVE HOMES INC.

Provider Business Mailing Address
First Line	:	PO BOX 707
Second Line	:
City	:	JOHNSTON
State	:	IA
Zip	:	50131-0707
Country	:	US
Telephone Number	:	515-727-8750
Fax Number	:	515-727-8757

Provider Business Practice Location Address
First Line	:	7161 WILSHIRE BLVD
Second Line	:
City	:	WINDSOR HEIGHTS
State	:	IA
Zip	:	50322-4823
Country	:	US
Telephone Number	:	515-276-3612
Fax Number	:	515-331-7706

Authorized Official
Title or Position	:	DIRECTOR OF ACCOUNTING
Name	:	RODNEY WILDRICK
Credential	:
Telephone Number	:	515-727-1468

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	07/10/2007

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