Provider Demographics
NPI:1164598868
Name:BOARD OF TRUSTEES GRAND CHARITY FUND GRAND LODGE OF IOWA A F & A M
Entity Type:Organization
Organization Name:BOARD OF TRUSTEES GRAND CHARITY FUND GRAND LODGE OF IOWA A F & A M
Other - Org Name:IOWA MASONIC HEALTH FACILITIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:TEGELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-499-7751
Mailing Address - Street 1:2500 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-5092
Mailing Address - Country:US
Mailing Address - Phone:563-359-9171
Mailing Address - Fax:563-359-6900
Practice Address - Street 1:2500 GRANT ST
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-5092
Practice Address - Country:US
Practice Address - Phone:563-359-9171
Practice Address - Fax:563-359-6900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA820296314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0802033Medicaid
IA65553OtherBCBS PROVIDER #
IA65553OtherBCBS PROVIDER #