Healthcare Provider Details

I. General information

NPI: 1649242074
Provider Name (Legal Business Name): BLACKHAWK LIFECARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 W 5TH ST
LAKE VIEW IA
51450-7312
US

IV. Provider business mailing address

73 W 5TH ST
LAKE VIEW IA
51450-7312
US

V. Phone/Fax

Practice location:
  • Phone: 712-657-8527
  • Fax: 712-657-8618
Mailing address:
  • Phone: 712-657-8527
  • Fax: 712-657-8618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number810547
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberN-547
License Number StateIA

VIII. Authorized Official

Name: LINDA K. JUCKETTE
Title or Position: PRESIDENT
Credential:
Phone: 515-223-6064