Provider Demographics
NPI:1902024417
Name:BLACK HAWK CENTER FOR INDEPENDENT LIVING
Entity Type:Organization
Organization Name:BLACK HAWK CENTER FOR INDEPENDENT LIVING
Other - Org Name:PRIME TIME PASS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-291-7755
Mailing Address - Street 1:312 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-1322
Mailing Address - Country:US
Mailing Address - Phone:319-291-7755
Mailing Address - Fax:319-291-7781
Practice Address - Street 1:312 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-1322
Practice Address - Country:US
Practice Address - Phone:319-291-7755
Practice Address - Fax:319-291-7781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0454736347B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347B00000XTransportation ServicesBus