Healthcare Provider Details

I. General information

NPI: 1508085879
Provider Name (Legal Business Name): APPLE VALLEY ASSISTED LIVING LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 27TH AVE S
CLEAR LAKE IA
50428-4002
US

IV. Provider business mailing address

405 27TH AVE S
CLEAR LAKE IA
50428-4002
US

V. Phone/Fax

Practice location:
  • Phone: 641-357-7083
  • Fax: 641-357-1512
Mailing address:
  • Phone: 641-357-7083
  • Fax: 641-357-1512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberS0166
License Number StateIA

VIII. Authorized Official

Name: MS. TERRI ANN COSSELMAN
Title or Position: ADMINISTRATOR
Credential: R.N.
Phone: 641-357-7083