Provider Demographics
NPI:1558415943
Name:FHC OF STORM LAKE IOWA INC
Entity Type:Organization
Organization Name:FHC OF STORM LAKE IOWA INC
Other - Org Name:FAITH HOPE & CHARITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-732-5117
Mailing Address - Street 1:PO BOX 243
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-0243
Mailing Address - Country:US
Mailing Address - Phone:712-732-5127
Mailing Address - Fax:712-732-6002
Practice Address - Street 1:1815 W MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-0243
Practice Address - Country:US
Practice Address - Phone:712-732-5127
Practice Address - Fax:712-732-6002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIMR439315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0880674Medicaid