Provider Demographics
NPI:1043208671
Name:ROTARY CLUB OF EAGLE GROVE HOME INC
Entity Type:Organization
Organization Name:ROTARY CLUB OF EAGLE GROVE HOME INC
Other - Org Name:ROTARY ANN NURSING HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-448-5124
Mailing Address - Street 1:620 SE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:50533-2477
Mailing Address - Country:US
Mailing Address - Phone:515-448-5124
Mailing Address - Fax:515-448-5167
Practice Address - Street 1:500 S BLAINE AVE
Practice Address - Street 2:
Practice Address - City:EAGLE GROVE
Practice Address - State:IA
Practice Address - Zip Code:50533-2429
Practice Address - Country:US
Practice Address - Phone:515-448-5123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA990615311Z00000X
IA990337314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0803536Medicaid
IA0891549Medicaid
165500Medicare Oscar/Certification