Provider Demographics
NPI:1306840152
Name:FAITH LUTHERAN HOME
Entity Type:Organization
Organization Name:FAITH LUTHERAN HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LADONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GUNDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-732-5511
Mailing Address - Street 1:914 DAVIDSON DR
Mailing Address - Street 2:
Mailing Address - City:OSAGE
Mailing Address - State:IA
Mailing Address - Zip Code:50461-1475
Mailing Address - Country:US
Mailing Address - Phone:641-732-5941
Mailing Address - Fax:
Practice Address - Street 1:914 DAVIDSON DR
Practice Address - Street 2:
Practice Address - City:OSAGE
Practice Address - State:IA
Practice Address - Zip Code:50461-1475
Practice Address - Country:US
Practice Address - Phone:641-732-5941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAN-081314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA65433OtherBLUE CROSS OF IOWA
IA0801233Medicaid
IA65433OtherBLUE CROSS OF IOWA