Healthcare Provider Details

I. General information

NPI: 1134265291
Provider Name (Legal Business Name): CHRISTIAN HOME ASSOCIATION-CHILDREN'S SQUARE U.S.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 01/27/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NORTH 6TH & AVE E
COUNCIL BLUFFS IA
51502-3008
US

IV. Provider business mailing address

PO BOX 8C
COUNCIL BLUFFS IA
51502-3008
US

V. Phone/Fax

Practice location:
  • Phone: 712-322-3700
  • Fax: 712-323-6968
Mailing address:
  • Phone: 712-322-3700
  • Fax: 712-323-6968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK J DUMAN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 712-322-3700