Provider Demographics
NPI:1285630541
Name:HIAWATHA CARE CENTER INC
Entity Type:Organization
Organization Name:HIAWATHA CARE CENTER INC
Other - Org Name:HIAWATHA CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:D
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-223-6064
Mailing Address - Street 1:405 N 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIAWATHA
Mailing Address - State:IA
Mailing Address - Zip Code:52233-2347
Mailing Address - Country:US
Mailing Address - Phone:319-378-8583
Mailing Address - Fax:319-378-8598
Practice Address - Street 1:405 N 15TH AVE
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:IA
Practice Address - Zip Code:52233-2347
Practice Address - Country:US
Practice Address - Phone:319-378-8583
Practice Address - Fax:319-378-8598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA570660313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0809236Medicaid
IA0809236Medicaid