Healthcare Provider Details

I. General information

NPI: 1932475142
Provider Name (Legal Business Name): TIPTON ADAPTIVE DAYCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 04/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 PARKVIEW CT
TIPTON IA
52772-1349
US

IV. Provider business mailing address

118 PARKVIEW CT
TIPTON IA
52772-1349
US

V. Phone/Fax

Practice location:
  • Phone: 563-886-3143
  • Fax: 563-886-3143
Mailing address:
  • Phone: 563-886-3143
  • Fax: 563-886-3143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number104423
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number104423
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number104423
License Number StateIA

VIII. Authorized Official

Name: MRS. DEBORAH LORRAINE VANDERGAAST
Title or Position: OWNER / DIRECTOR
Credential: RN
Phone: 563-886-3143