Provider Demographics
NPI:1548386675
Name:LONGHOUSE-NORTHSHIRE, LTD
Entity Type:Organization
Organization Name:LONGHOUSE-NORTHSHIRE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST ADM
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUCEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-262-2344
Mailing Address - Street 1:711 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-3237
Mailing Address - Country:US
Mailing Address - Phone:712-262-2344
Mailing Address - Fax:712-262-3550
Practice Address - Street 1:711 W 11TH ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-3237
Practice Address - Country:US
Practice Address - Phone:712-262-2344
Practice Address - Fax:712-262-3550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA210065313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0804989Medicaid
IA165449Medicare Oscar/Certification