Healthcare Provider Details

I. General information

NPI: 1538566732
Provider Name (Legal Business Name): ST JUDE RETREAT HOUSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 12/03/2014
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: 515-421-4066
  • Fax:
Mailing address:
  • Phone: 515-421-4066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: TIM F CARSON
Title or Position: CFO
Credential:
Phone: 515-298-7209