Provider Demographics
NPI:1417283789
Name:ST. MARY HEALTHCARE AND REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:ST. MARY HEALTHCARE AND REHABILITATION CENTER, LLC
Other - Org Name:ST. MARY HEALTHCARE AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:800 E RUSHOLME ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2547
Mailing Address - Country:US
Mailing Address - Phone:563-322-1668
Mailing Address - Fax:563-326-1811
Practice Address - Street 1:800 E RUSHOLME ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2547
Practice Address - Country:US
Practice Address - Phone:563-322-1668
Practice Address - Fax:563-326-1811
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUMMIT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-21
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA820846314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1417283789Medicaid
IA1417283789Medicaid