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General NPI Number Information
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NPI Number | 1619046596
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Entity Type | Organization
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Legal Business Name | EASTERN STAR MASONIC HOME
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 01/27/2025
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Provider Practice Location Address
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Address Line | 715 W MAMIE EISENHOWER AVE
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City | BOONE
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State | IA
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Zip | 50036-3930
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Country | US
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Telephone | 515-432-5274
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Fax | 515-432-5276
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Provider Business Mailing Address
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Address Line | 715 W MAMIE EISENHOWER AVE
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City | BOONE
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State | IA
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Zip | 50036-3930
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Country | US
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Telephone | 515-432-5274
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Fax | 515-432-5276
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Authorized Official
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Title or Position | DIRECTOR OF COMPLIANCE
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Name | SCOTT DYLAN ARMSTRONG
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Credential |
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Telephone | 515-709-4398
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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-268
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License Number State | IA
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