Provider Demographics
NPI:1649168337
Name:PASSION HEALTH CARE PROVIDER LLC
Entity type:Organization
Organization Name:PASSION HEALTH CARE PROVIDER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:MBACHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-525-5369
Mailing Address - Street 1:208 NW DRIFTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-6817
Mailing Address - Country:US
Mailing Address - Phone:515-525-5369
Mailing Address - Fax:
Practice Address - Street 1:208 NW DRIFTWOOD CT
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-6817
Practice Address - Country:US
Practice Address - Phone:515-525-5369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities