=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992353411
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMERISERVE INTERNATIONAL II, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2019
-----------------------------------------------------
Last Update Date | 08/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 MAIN PL STE 300
-----------------------------------------------------
City | COUNCIL BLUFFS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51503-0702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-322-0272
-----------------------------------------------------
Fax | 712-322-0272
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35 MAIN PL STE 300
-----------------------------------------------------
City | COUNCIL BLUFFS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51503-0702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-322-0272
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREASURER
-----------------------------------------------------
Name | STEVEN B PEARSON
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 712-322-0272
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------