Provider Demographics
NPI:1417544206
Name:MIDWEST COMFORTABLE LIVING LLC
Entity Type:Organization
Organization Name:MIDWEST COMFORTABLE LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOQUANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-824-2988
Mailing Address - Street 1:811 SE 10TH LN
Mailing Address - Street 2:
Mailing Address - City:GRIMES
Mailing Address - State:IA
Mailing Address - Zip Code:50111-3006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:319 S 17TH ST STE 722
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-1911
Practice Address - Country:US
Practice Address - Phone:402-378-5755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE98864151Medicaid