Provider Demographics
NPI:1023005105
Name:MARJAN MANAGEMENT SERVICES LTD
Entity Type:Organization
Organization Name:MARJAN MANAGEMENT SERVICES LTD
Other - Org Name:NORTHBROOK MANOR CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRES ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:TAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:319-393-1447
Mailing Address - Street 1:6420 COUNCIL ST NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-1129
Mailing Address - Country:US
Mailing Address - Phone:319-393-1447
Mailing Address - Fax:319-378-9533
Practice Address - Street 1:6420 COUNCIL ST NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-1129
Practice Address - Country:US
Practice Address - Phone:319-393-1447
Practice Address - Fax:319-378-9533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA720313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA165587Medicare Oscar/Certification