Provider Demographics
NPI:1558799031
Name:CCRC OF ALTOONA LLC
Entity Type:Organization
Organization Name:CCRC OF ALTOONA LLC
Other - Org Name:PRAIRIE VISTA VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:GULLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-890-4782
Mailing Address - Street 1:11827 W 112TH ST
Mailing Address - Street 2:STE 103
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2726
Mailing Address - Country:US
Mailing Address - Phone:913-890-4782
Mailing Address - Fax:913-956-6564
Practice Address - Street 1:2785 1ST AVE S
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:IA
Practice Address - Zip Code:50009-8820
Practice Address - Country:US
Practice Address - Phone:515-967-8700
Practice Address - Fax:515-967-6032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-21
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0800115Medicaid
IA0800115Medicaid