Healthcare Provider Details

I. General information

NPI: 1760475487
Provider Name (Legal Business Name): QHC HUMBOLDT SOUTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2005
Last Update Date: 12/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 13TH ST S
HUMBOLDT IA
50548-2439
US

IV. Provider business mailing address

8350 HICKMAN RD SUITE 15
DES MOINES IA
50325-4311
US

V. Phone/Fax

Practice location:
  • Phone: 515-332-4104
  • Fax: 515-332-4526
Mailing address:
  • Phone: 515-276-3656
  • Fax: 515-276-4353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0800050
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier0800050
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: JERRY WILLIAM VOYNA
Title or Position: OWNER
Credential: CPA
Phone: 515-276-3656