Provider Demographics
NPI:1457310716
Name:CENTERS FOR LONG TERM CARE OF IOWA, INC
Entity Type:Organization
Organization Name:CENTERS FOR LONG TERM CARE OF IOWA, INC
Other - Org Name:CLC CARROLL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:TREBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-359-2000
Mailing Address - Street 1:PO BOX 155635
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76155-0635
Mailing Address - Country:US
Mailing Address - Phone:817-359-2000
Mailing Address - Fax:817-359-2093
Practice Address - Street 1:500 VALLEY DRIVE
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401
Practice Address - Country:US
Practice Address - Phone:712-792-9281
Practice Address - Fax:712-792-6750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0654228Medicaid
IA0654228Medicaid