Provider Demographics
NPI:1508849522
Name:CLARENCE NURSING HOME INC
Entity Type:Organization
Organization Name:CLARENCE NURSING HOME INC
Other - Org Name:CLARENCE NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:DIRCKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-452-3262
Mailing Address - Street 1:402 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CLARENCE
Mailing Address - State:IA
Mailing Address - Zip Code:52216-9754
Mailing Address - Country:US
Mailing Address - Phone:563-452-3262
Mailing Address - Fax:563-452-3848
Practice Address - Street 1:402 2ND AVE
Practice Address - Street 2:PO BOX H
Practice Address - City:CLARENCE
Practice Address - State:IA
Practice Address - Zip Code:52216-9754
Practice Address - Country:US
Practice Address - Phone:563-452-3262
Practice Address - Fax:563-452-3848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAN149314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0800599Medicaid
IA165590Medicare Oscar/Certification