Healthcare Provider Details

I. General information

NPI: 1760192702
Provider Name (Legal Business Name): GREATLIFE HOME CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7880 HARBACH BLVD
CLIVE IA
50325-1240
US

IV. Provider business mailing address

10069 LINCOLN AVE
CLIVE IA
50325-6745
US

V. Phone/Fax

Practice location:
  • Phone: 515-918-3551
  • Fax:
Mailing address:
  • Phone: 515-918-3551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number
License Number StateNULL

VIII. Authorized Official

Name: MASSARA GOYOM KOMJO
Title or Position: OWNER
Credential:
Phone: 515-918-3551