Provider Demographics
NPI:1386861045
Name:COMMUNITY OUTREACH SERVICES, LLC
Entity Type:Organization
Organization Name:COMMUNITY OUTREACH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:BUSTAMANTE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMHC, LPHA
Authorized Official - Phone:515-727-0702
Mailing Address - Street 1:PO BOX 816
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-0816
Mailing Address - Country:US
Mailing Address - Phone:515-309-1204
Mailing Address - Fax:515-309-2525
Practice Address - Street 1:5870 MERLE HAY RD
Practice Address - Street 2:SUITE D
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-2816
Practice Address - Country:US
Practice Address - Phone:515-309-1204
Practice Address - Fax:515-309-2525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0011312Medicaid
IA1011312Medicaid
IA0469106Medicaid