Provider Demographics
NPI:1649239492
Name:MONTICELLO NURSING HOME COMPANY
Entity Type:Organization
Organization Name:MONTICELLO NURSING HOME COMPANY
Other - Org Name:MONTICELLO NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHENSVOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-362-8916
Mailing Address - Street 1:500 PINEHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IA
Mailing Address - Zip Code:52310-2049
Mailing Address - Country:US
Mailing Address - Phone:319-465-5415
Mailing Address - Fax:319-465-3205
Practice Address - Street 1:500 PINEHAVEN DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IA
Practice Address - Zip Code:52310-2049
Practice Address - Country:US
Practice Address - Phone:319-465-5415
Practice Address - Fax:319-465-3205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA530729314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA16D0667011OtherCLIA
IA0809194Medicaid
IA16D0667011OtherCLIA