Healthcare Provider Details

I. General information

NPI: 1619253051
Provider Name (Legal Business Name): NORTH CENTRAL IOWA MENTAL HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2011
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date: 12/29/2011
Reactivation Date: 04/24/2012

III. Provider practice location address

1000 15TH ST N
HUMBOLDT IA
50548-1008
US

IV. Provider business mailing address

720 KENYON RD
FORT DODGE IA
50501-5759
US

V. Phone/Fax

Practice location:
  • Phone: 800-482-8305
  • Fax: 515-573-7898
Mailing address:
  • Phone: 800-482-8305
  • Fax: 515-573-7898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier0159608
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier07466
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK BCBS

VIII. Authorized Official

Name: AARON D MCHONE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 800-482-8305