Provider Demographics
NPI:1942293667
Name:QHC FORT DODGE VILLA LLC
Entity Type:Organization
Organization Name:QHC FORT DODGE VILLA LLC
Other - Org Name:FORT DODGE VILLA CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:VOYNA
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:515-276-3656
Mailing Address - Street 1:8350 HICKMAN RD
Mailing Address - Street 2:SUITE 15
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-4311
Mailing Address - Country:US
Mailing Address - Phone:515-276-3656
Mailing Address - Fax:515-276-4353
Practice Address - Street 1:2721 10TH AVE N
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-2834
Practice Address - Country:US
Practice Address - Phone:515-576-7525
Practice Address - Fax:515-955-7528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-28
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0800053314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0800053Medicaid
165265Medicare Oscar/Certification
IA0801340Medicaid