Healthcare Provider Details

I. General information

NPI: 1962546374
Provider Name (Legal Business Name): CHILDSERVE HABILITATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 PIONEER PKWY
JOHNSTON IA
50131-1569
US

IV. Provider business mailing address

PO BOX 707
JOHNSTON IA
50131-0707
US

V. Phone/Fax

Practice location:
  • Phone: 515-270-2205
  • Fax: 515-276-0140
Mailing address:
  • Phone: 515-727-8750
  • Fax: 515-727-8757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number770916
License Number StateIA

VIII. Authorized Official

Name: RODNEY WILDRICK
Title or Position: DIRECTOR OF ACCOUNTING
Credential:
Phone: 515-727-1468