Provider Demographics
NPI:1407073893
Name:EVANS MEMORIAL HOME
Entity Type:Organization
Organization Name:EVANS MEMORIAL HOME
Other - Org Name:CRESCO ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHENSVOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-362-8916
Mailing Address - Street 1:1004 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:CRESCO
Mailing Address - State:IA
Mailing Address - Zip Code:52136-1097
Mailing Address - Country:US
Mailing Address - Phone:563-547-2580
Mailing Address - Fax:563-547-5013
Practice Address - Street 1:1004 N ELM ST
Practice Address - Street 2:
Practice Address - City:CRESCO
Practice Address - State:IA
Practice Address - Zip Code:52136-1097
Practice Address - Country:US
Practice Address - Phone:563-547-2580
Practice Address - Fax:563-547-5013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0210310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0461590Medicaid