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General NPI Number Information
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NPI Number | 1104825876
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE RETIREMENT HOME OF SIOUX CITY, IOWA
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Dates
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Enumeration Date | 07/15/2005
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Last Update Date | 09/11/2009
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Provider Practice Location Address
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Address Line | 6120 MORNINGSIDE AVE
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City | SIOUX CITY
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State | IA
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Zip | 51106-3943
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Country | US
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Telephone | 712-276-3000
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Fax | 712-266-2167
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Provider Business Mailing Address
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Address Line | 6120 MORNINGSIDE AVE
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City | SIOUX CITY
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State | IA
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Zip | 51106-3943
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Country | US
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Telephone | 712-276-3000
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Fax | 712-266-2167
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DEBBIE MENZENBERG
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Credential |
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Telephone | 712-276-3000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311Z00000X
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Taxonomy Name | Custodial Care Facility
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License Number | R-0370
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | N-0370
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License Number State | IA
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