Healthcare Provider Details

I. General information

NPI: 1104914639
Provider Name (Legal Business Name): COUNTRY WINDS MANOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21668 80TH ST
CRESCO IA
52136-8412
US

IV. Provider business mailing address

21668 80TH ST
CRESCO IA
52136-8412
US

V. Phone/Fax

Practice location:
  • Phone: 563-547-2398
  • Fax: 563-547-4274
Mailing address:
  • Phone: 563-547-2398
  • Fax: 563-547-4274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberCCDI-478
License Number StateIA

VIII. Authorized Official

Name: MR. PATRICK D OGDEN
Title or Position: ADMINISTRATOR
Credential:
Phone: 563-547-2398