Provider Demographics
NPI:1851442909
Name:ELDERBRIDGE AGENCY ON AGING
Entity Type:Organization
Organization Name:ELDERBRIDGE AGENCY ON AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAHOMA
Authorized Official - Middle Name:
Authorized Official - Last Name:COUNTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-424-0678
Mailing Address - Street 1:22 N GEORGIA AVE
Mailing Address - Street 2:SUITE 216
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-3435
Mailing Address - Country:US
Mailing Address - Phone:641-424-0678
Mailing Address - Fax:
Practice Address - Street 1:22 N GEORGIA AVE
Practice Address - Street 2:SUITE 216
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-3435
Practice Address - Country:US
Practice Address - Phone:641-424-0678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0133215Medicaid