Provider Demographics
NPI:1003901778
Name:SPECTRUM INDUSTRIES
Entity Type:Organization
Organization Name:SPECTRUM INDUSTRIES
Other - Org Name:THE SPECTRUM NETWORK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TEUNISJE
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:BOORD SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-382-8401
Mailing Address - Street 1:PO BOX 22
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-0022
Mailing Address - Country:US
Mailing Address - Phone:563-382-8401
Mailing Address - Fax:563-382-8403
Practice Address - Street 1:607 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2265
Practice Address - Country:US
Practice Address - Phone:563-382-8401
Practice Address - Fax:563-382-8403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0166983Medicaid
IA02-35754Medicaid
IA12-35754Medicaid
IA2235754Medicaid