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General NPI Number Information
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NPI Number | 1316757743
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Entity Type | Organization
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Legal Business Name | PREMIER WAIVER HOMES LLC
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Dates
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Enumeration Date | 01/08/2025
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Last Update Date | 01/23/2025
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Provider Practice Location Address
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Address Line | 701 WEST ST
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City | SHENANDOAH
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State | IA
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Zip | 51601-1936
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Country | US
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Telephone | 712-242-5993
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Fax | 515-655-8519
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Provider Business Mailing Address
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Address Line | PO BOX 364
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City | CLARINDA
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State | IA
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Zip | 51632-0364
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Country | US
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Telephone | 712-242-5993
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Fax |
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Authorized Official
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Title or Position | FOUNDER
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Name | SETH ANDREW HUDSON
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Credential |
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Telephone | 712-870-4793
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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