Healthcare Provider Details

I. General information

NPI: 1336484831
Provider Name (Legal Business Name): ST. GREGORY RETREAT CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 12/10/2012
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: 515-298-7209
  • Fax: 631-410-1394
Mailing address:
  • Phone: 515-298-7209
  • Fax: 631-410-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1332
License Number StateIA

VIII. Authorized Official

Name: MICHAEL J VASQUEZ
Title or Position: CEO
Credential:
Phone: 515-421-4065