Provider Demographics
NPI:1629397211
Name:COUNCIL BLUFFS SENIOR CARE, LLC
Entity Type:Organization
Organization Name:COUNCIL BLUFFS SENIOR CARE, LLC
Other - Org Name:MCPHERSON HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MORAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-909-8388
Mailing Address - Street 1:1600 MCPHERSON AVE
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-4858
Mailing Address - Country:US
Mailing Address - Phone:712-322-9285
Mailing Address - Fax:712-322-7771
Practice Address - Street 1:1600 MCPHERSON AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4858
Practice Address - Country:US
Practice Address - Phone:712-322-9285
Practice Address - Fax:712-322-7771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-22
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA780151314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0800035Medicaid
IA165200Medicare Oscar/Certification