Healthcare Provider Details

I. General information

NPI: 1043208671
Provider Name (Legal Business Name): ROTARY CLUB OF EAGLE GROVE HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S BLAINE AVE
EAGLE GROVE IA
50533-2429
US

IV. Provider business mailing address

620 SE 5TH ST
EAGLE GROVE IA
50533-2477
US

V. Phone/Fax

Practice location:
  • Phone: 515-448-5123
  • Fax:
Mailing address:
  • Phone: 515-448-5124
  • Fax: 515-448-5167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number990615
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number990337
License Number StateIA

VIII. Authorized Official

Name: STEPHANIE MORRIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 515-448-5124