Provider Demographics
NPI:1124224969
Name:PRIME NURSING AND REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:PRIME NURSING AND REHABILITATION CENTER, LLC
Other - Org Name:PRIME NURSING & REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GROSENHEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-540-3332
Mailing Address - Street 1:600 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-5418
Mailing Address - Country:US
Mailing Address - Phone:515-243-6195
Mailing Address - Fax:515-243-6913
Practice Address - Street 1:600 E 5TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-5418
Practice Address - Country:US
Practice Address - Phone:515-243-6195
Practice Address - Fax:515-243-6913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA770236314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0800013Medicaid
IA165588Medicare Oscar/Certification