Provider Demographics
NPI:1689986887
Name:STORY COUNTY COMMUNITY LIFE PROGRAM
Entity Type:Organization
Organization Name:STORY COUNTY COMMUNITY LIFE PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAYLA
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARKEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:515-956-2602
Mailing Address - Street 1:104 S HAZEL AVE
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-5952
Mailing Address - Country:US
Mailing Address - Phone:515-956-2600
Mailing Address - Fax:515-956-2609
Practice Address - Street 1:104 S HAZEL AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-5952
Practice Address - Country:US
Practice Address - Phone:515-956-2600
Practice Address - Fax:515-956-2609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1366516114Medicaid