Provider Demographics
NPI:1518975770
Name:CEDAR VALLEY RANCH
Entity Type:Organization
Organization Name:CEDAR VALLEY RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED NUSRING HOM
Authorized Official - Phone:319-472-2671
Mailing Address - Street 1:2591 61ST STREET LANE
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52349
Mailing Address - Country:US
Mailing Address - Phone:319-472-2671
Mailing Address - Fax:319-472-5068
Practice Address - Street 1:2591 61ST STREET LANE
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:IA
Practice Address - Zip Code:52349
Practice Address - Country:US
Practice Address - Phone:319-472-2671
Practice Address - Fax:319-472-5068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA060691320800000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Not Answered320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0252072OtherARO
IA0895581Medicaid