Provider Demographics
NPI:1932495389
Name:JP SENIOR HEALTHCARE LLC
Entity Type:Organization
Organization Name:JP SENIOR HEALTHCARE LLC
Other - Org Name:NORTH LAKE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-574-7312
Mailing Address - Street 1:PO BOX 2246
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-0246
Mailing Address - Country:US
Mailing Address - Phone:712-574-7312
Mailing Address - Fax:712-277-8313
Practice Address - Street 1:1325 LAKE AVE
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-1907
Practice Address - Country:US
Practice Address - Phone:712-732-3254
Practice Address - Fax:712-732-1990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-23
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA110129314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0800056Medicaid
IA165596Medicare Oscar/Certification