Healthcare Provider Details

I. General information

NPI: 1376670034
Provider Name (Legal Business Name): CENTER VILLAGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19248 MAPLE AVE
KEOSAUQUA IA
52565-8288
US

IV. Provider business mailing address

19248 MAPLE AVE
KEOSAUQUA IA
52565-8288
US

V. Phone/Fax

Practice location:
  • Phone: 319-293-3107
  • Fax: 319-293-3885
Mailing address:
  • Phone: 319-293-3107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number0895839
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number890403
License Number StateIA

VIII. Authorized Official

Name: MRS. KARLA N WINSLOW
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 319-293-3107