Provider Demographics
NPI:1679779490
Name:KEOKUK AREA GROUP HOME
Entity Type:Organization
Organization Name:KEOKUK AREA GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CEVIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:COFFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-524-1871
Mailing Address - Street 1:317 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-5939
Mailing Address - Country:US
Mailing Address - Phone:319-524-1871
Mailing Address - Fax:
Practice Address - Street 1:317 HIGH ST
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-5939
Practice Address - Country:US
Practice Address - Phone:319-524-1871
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA56-0091320600000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities