Provider Demographics
NPI:1184837593
Name:THE ELLEN KENNEDY LIVING CENTER
Entity Type:Organization
Organization Name:THE ELLEN KENNEDY LIVING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARI
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:WITTMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-875-6323
Mailing Address - Street 1:1177 7TH ST SW
Mailing Address - Street 2:STE #1
Mailing Address - City:DYERSVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52040-2513
Mailing Address - Country:US
Mailing Address - Phone:563-875-6323
Mailing Address - Fax:563-875-6268
Practice Address - Street 1:1177 7TH ST SW
Practice Address - Street 2:STE #1
Practice Address - City:DYERSVILLE
Practice Address - State:IA
Practice Address - Zip Code:52040-2513
Practice Address - Country:US
Practice Address - Phone:563-875-6323
Practice Address - Fax:563-875-6268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0155310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0282384Medicaid