Provider Demographics
NPI:1104022953
Name:GREAT RIVER CHILD CARE INC.
Entity Type:Organization
Organization Name:GREAT RIVER CHILD CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:K
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-752-0940
Mailing Address - Street 1:639 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601-3946
Mailing Address - Country:US
Mailing Address - Phone:319-752-0940
Mailing Address - Fax:319-752-0941
Practice Address - Street 1:639 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-3946
Practice Address - Country:US
Practice Address - Phone:319-752-0940
Practice Address - Fax:319-752-0941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA4129000011385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0418160Medicaid