Healthcare Provider Details

I. General information

NPI: 1083016174
Provider Name (Legal Business Name): STILL WATER HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 E 9TH ST
DES MOINES IA
50316-2261
US

IV. Provider business mailing address

1414 E 9TH ST
DES MOINES IA
50316-2261
US

V. Phone/Fax

Practice location:
  • Phone: 515-441-0708
  • Fax:
Mailing address:
  • Phone: 515-441-0708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberR 148120-4
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License NumberR 148120-4
License Number StateMN

VIII. Authorized Official

Name: RITA JOHNSON MARTOR
Title or Position: OWNER 1
Credential:
Phone: 515-441-0708