Healthcare Provider Details

I. General information

NPI: 1841666054
Provider Name (Legal Business Name): JP SENIOR HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SERGEANT SQUARE DRIVE
SERGEANT BLUFF IA
51054
US

IV. Provider business mailing address

PO BOX 2246
SIOUX CITY IA
51104-0246
US

V. Phone/Fax

Practice location:
  • Phone: 712-574-7312
  • Fax:
Mailing address:
  • Phone: 712-574-7312
  • Fax: 712-277-8313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier0800187
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: MR. JOSEPH P DEWITT
Title or Position: CFO
Credential:
Phone: 712-574-7312