Healthcare Provider Details

I. General information

NPI: 1740246883
Provider Name (Legal Business Name): HAWKEYE CARE CENTER OF CRESCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 09/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 VERNON RD
CRESCO IA
52136-1944
US

IV. Provider business mailing address

1912 ZENITH AVE SUITE 2526
SPIRIT LAKE IA
51360-1000
US

V. Phone/Fax

Practice location:
  • Phone: 563-547-3580
  • Fax: 563-547-3532
Mailing address:
  • Phone: 712-759-1321
  • Fax: 712-759-1322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number450905
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier0809467
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: DOUG JOHNSON
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 515-223-0173