Healthcare Provider Details

I. General information

NPI: 1235643941
Provider Name (Legal Business Name): CEDAR RAPIDS IA HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2017
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 PARK PL NE
CEDAR RAPIDS IA
52402-2001
US

IV. Provider business mailing address

1221 PARK PL NE
CEDAR RAPIDS IA
52402-2001
US

V. Phone/Fax

Practice location:
  • Phone: 319-320-2069
  • Fax:
Mailing address:
  • Phone: 319-320-2069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MR. ANTHONY RAY BETTERS JR.
Title or Position: OWNER/ DIRECTOR
Credential:
Phone: 319-320-2069