Healthcare Provider Details

I. General information

NPI: 1598839359
Provider Name (Legal Business Name): HUMBOLDT WORKSHOP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 TAFT ST N
HUMBOLDT IA
50548-1768
US

IV. Provider business mailing address

21 TAFT ST N
HUMBOLDT IA
50548-1768
US

V. Phone/Fax

Practice location:
  • Phone: 515-332-2841
  • Fax: 515-332-1915
Mailing address:
  • Phone: 515-332-2841
  • Fax: 515-332-1915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier0137869
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: MRS. JOAN MARIE KELLNER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 515-332-2841