Provider Demographics
NPI:1578541611
Name:ENOBLE MANOR CARE CENTER INC.
Entity Type:Organization
Organization Name:ENOBLE MANOR CARE CENTER INC.
Other - Org Name:ENNOBLE MANOR CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:D
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-223-6064
Mailing Address - Street 1:2000 PASADENA DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-0808
Mailing Address - Country:US
Mailing Address - Phone:563-557-1076
Mailing Address - Fax:563-584-0671
Practice Address - Street 1:2000 PASADENA DR
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-0808
Practice Address - Country:US
Practice Address - Phone:563-557-1076
Practice Address - Fax:563-584-0671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA310764314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0801183Medicaid
IA0801183Medicaid
IA1578541611Medicare Oscar/Certification