Provider Demographics
NPI:1689752297
Name:SHADY REST, INC.
Entity Type:Organization
Organization Name:SHADY REST, INC.
Other - Org Name:SHADY REST CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:VOLK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-852-3277
Mailing Address - Street 1:701 JOHNSON ST NW
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:IA
Mailing Address - Zip Code:52033-7747
Mailing Address - Country:US
Mailing Address - Phone:563-852-3277
Mailing Address - Fax:563-852-7205
Practice Address - Street 1:701 JOHNSON ST NW
Practice Address - Street 2:
Practice Address - City:CASCADE
Practice Address - State:IA
Practice Address - Zip Code:52033-7747
Practice Address - Country:US
Practice Address - Phone:563-852-3277
Practice Address - Fax:563-852-7205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA310255311500000X
IAI-255314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0803627Medicaid
IA165568Medicare Oscar/Certification