Healthcare Provider Details

I. General information

NPI: 1619046596
Provider Name (Legal Business Name): EASTERN STAR MASONIC HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 W MAMIE EISENHOWER AVE
BOONE IA
50036-3930
US

IV. Provider business mailing address

715 W MAMIE EISENHOWER AVE
BOONE IA
50036-3930
US

V. Phone/Fax

Practice location:
  • Phone: 515-432-5274
  • Fax: 515-432-5276
Mailing address:
  • Phone: 515-432-5274
  • Fax: 515-432-5276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License NumberR-268
License Number StateIA

VIII. Authorized Official

Name: SCOTT DYLAN ARMSTRONG
Title or Position: DIRECTOR OF COMPLIANCE
Credential:
Phone: 515-709-4398