Healthcare Provider Details

I. General information

NPI: 1477533362
Provider Name (Legal Business Name): FORT MADISON HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 41ST ST
FORT MADISON IA
52627-3269
US

IV. Provider business mailing address

1702 41ST ST
FORT MADISON IA
52627-3269
US

V. Phone/Fax

Practice location:
  • Phone: 319-372-8021
  • Fax: 319-372-8163
Mailing address:
  • Phone: 319-372-8021
  • Fax: 319-372-8163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number195
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0801266
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: WAYNE MARPLE
Title or Position: CHIEF FINANCIAL OPERATOR
Credential:
Phone: 319-372-4920