Provider Demographics
NPI:1821091026
Name:DES MOINES VALLEY HEALTH AND HUMAN SERVICES
Entity Type:Organization
Organization Name:DES MOINES VALLEY HEALTH AND HUMAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FISCAL OFFICER/EXECUTIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:BEZDICEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-847-2366
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MN
Mailing Address - Zip Code:56143-0067
Mailing Address - Country:US
Mailing Address - Phone:507-847-2366
Mailing Address - Fax:507-847-2881
Practice Address - Street 1:402 WHITE ST
Practice Address - Street 2:STE 201
Practice Address - City:JACKSON
Practice Address - State:MN
Practice Address - Zip Code:56143-1572
Practice Address - Country:US
Practice Address - Phone:507-847-2366
Practice Address - Fax:507-847-2881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN325717251K00000X, 251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN510755500Medicaid
MN510755500Medicaid