Healthcare Provider Details

I. General information

NPI: 1063485365
Provider Name (Legal Business Name): HOSPICE OF SIOUXLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 COOK ST
SIOUX CITY IA
51103-3707
US

IV. Provider business mailing address

309 COOK ST
SIOUX CITY IA
51103-3707
US

V. Phone/Fax

Practice location:
  • Phone: 712-233-4144
  • Fax:
Mailing address:
  • Phone: 712-233-4144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier0615021
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier10025149000
Identifier TypeMEDICAID
Identifier StateNE
Identifier Issuer
# 3
Identifier0154102
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name: JACQUELINE M. KREBER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 712-252-9301