Healthcare Provider Details

I. General information

NPI: 1639348873
Provider Name (Legal Business Name): FRIENDSHIP VILLAGE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2008
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 PARK LN
WATERLOO IA
50702-5200
US

IV. Provider business mailing address

600 PARK LN
WATERLOO IA
50702-5200
US

V. Phone/Fax

Practice location:
  • Phone: 319-291-8100
  • Fax: 319-291-8324
Mailing address:
  • Phone: 319-291-8100
  • Fax: 319-291-8324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberN429
License Number StateIA

VIII. Authorized Official

Name: LISA E GATES
Title or Position: CFO
Credential:
Phone: 319-291-8100