Provider Demographics
NPI:1417944265
Name:EVENTIDE
Entity Type:Organization
Organization Name:EVENTIDE
Other - Org Name:EVENTIDE LUTHERAN HOME FOR THE AGED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MINDI
Authorized Official - Middle Name:RENAE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:712-263-3114
Mailing Address - Street 1:114 S 20TH ST
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:IA
Mailing Address - Zip Code:51442-2251
Mailing Address - Country:US
Mailing Address - Phone:712-263-3114
Mailing Address - Fax:712-263-8819
Practice Address - Street 1:114 S 20TH ST
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:IA
Practice Address - Zip Code:51442-2251
Practice Address - Country:US
Practice Address - Phone:712-263-3114
Practice Address - Fax:712-263-8819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0890475311Z00000X
313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0801217Medicaid
IA0890475Medicaid
IA0890475Medicaid