MEDICARE: BOARD OF TRUSTEES GRAND CHARITY FUND GRAND LODGE OF IOWA A F & A M

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	314000000X	Skilled Nursing Facility	820296	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	65553	OTHER	IA	BCBS PROVIDER #

General Provider Information

NPI Number	:	1164598868
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOARD OF TRUSTEES GRAND CHARITY FUND GRAND LODGE OF IOWA A F & A M

Provider Business Mailing Address
First Line	:	2500 GRANT ST
Second Line	:
City	:	BETTENDORF
State	:	IA
Zip	:	52722-5092
Country	:	US
Telephone Number	:	563-359-9171
Fax Number	:	563-359-6900

Provider Business Practice Location Address
First Line	:	2500 GRANT ST
Second Line	:
City	:	BETTENDORF
State	:	IA
Zip	:	52722-5092
Country	:	US
Telephone Number	:	563-359-9171
Fax Number	:	563-359-6900

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	TAMI TEGELER
Credential	:
Telephone Number	:	815-499-7751

Provider Enumeration Date	:	11/27/2006
Last Update Date	:	04/19/2024

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