Provider Demographics
NPI:1073798989
Name:LIGHT OF FAITH COMM. SERVICES
Entity Type:Organization
Organization Name:LIGHT OF FAITH COMM. SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FISCELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-682-0023
Mailing Address - Street 1:1317 N. ELM ST.
Mailing Address - Street 2:
Mailing Address - City:OTTUWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501
Mailing Address - Country:US
Mailing Address - Phone:641-682-0023
Mailing Address - Fax:641-682-1777
Practice Address - Street 1:1317 N. ELM ST.
Practice Address - Street 2:
Practice Address - City:OTTUWA
Practice Address - State:IA
Practice Address - Zip Code:52501
Practice Address - Country:US
Practice Address - Phone:641-682-0023
Practice Address - Fax:641-682-1777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAX000200331251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA200331Medicaid
IAX00020031Medicaid