Healthcare Provider Details

I. General information

NPI: 1184943797
Provider Name (Legal Business Name): ST. JUDE RETREAT HOUSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2010
Last Update Date: 12/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5875 FLEUR DR
DES MOINES IA
50321-2883
US

IV. Provider business mailing address

5875 FLEUR DR
DES MOINES IA
50321-2883
US

V. Phone/Fax

Practice location:
  • Phone: 800-990-0340
  • Fax: 954-208-5770
Mailing address:
  • Phone: 800-990-0340
  • Fax: 954-208-5770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1340
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA054289
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01930
License Number StateIA

VIII. Authorized Official

Name: MIKE VASQUEZ
Title or Position: CEO
Credential:
Phone: 800-990-0340