Healthcare Provider Details

I. General information

NPI: 1497740443
Provider Name (Legal Business Name): METH WICK COMMUNITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 13TH ST NW
CEDAR RAPIDS IA
52405-2404
US

IV. Provider business mailing address

1224 13TH ST NW
CEDAR RAPIDS IA
52405-2404
US

V. Phone/Fax

Practice location:
  • Phone: 319-365-9171
  • Fax: 319-364-5033
Mailing address:
  • Phone: 319-365-9171
  • Fax: 319-364-5033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number165542
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0802678
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier65542
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerBLUE CROSS BLUE SHEILD

VIII. Authorized Official

Name: MRS. SUSAN SCHMITT
Title or Position: ADMINISTRATOR
Credential:
Phone: 319-365-9171