Healthcare Provider Details

I. General information

NPI: 1376264366
Provider Name (Legal Business Name): QUAD CITIES INTERFAITH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3420 JERSEY RIDGE RD
DAVENPORT IA
52807-2222
US

IV. Provider business mailing address

3420 JERSEY RIDGE RD
DAVENPORT IA
52807-2222
US

V. Phone/Fax

Practice location:
  • Phone: 563-241-2969
  • Fax:
Mailing address:
  • Phone: 563-241-2969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: AMBER BORDOLO
Title or Position: EXECUTIVE DIRECTOR
Credential: MA
Phone: 563-241-2969