MEDICARE: COMMUNITY CARE OF IOWA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1043931090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CARE OF IOWA, LLC

Provider Business Mailing Address
First Line	:	508 WESTRIDGE DR
Second Line	:
City	:	CARROLL
State	:	IA
Zip	:	51401-3294
Country	:	US
Telephone Number	:	712-210-6296
Fax Number	:

Provider Business Practice Location Address
First Line	:	4755 PARKRIDGE AVE
Second Line	:
City	:	PLEASANT HILL
State	:	IA
Zip	:	50327-7228
Country	:	US
Telephone Number	:	712-210-6296
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRUCE BOEHM JR.
Credential	:	LNHA
Telephone Number	:	712-210-6296

Provider Enumeration Date	:	09/08/2022
Last Update Date	:	09/08/2022

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