Provider Demographics
NPI:1972650158
Name:DEPARTMENT OF HUMAN SERVICES GLENWOOD RESOURCE CENTER
Entity Type:Organization
Organization Name:DEPARTMENT OF HUMAN SERVICES GLENWOOD RESOURCE CENTER
Other - Org Name:FAMILY SUPPORT & OUTREACH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREATMENT SERVICE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RANDI
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLOYED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-525-1395
Mailing Address - Street 1:711 S VINE ST
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:51534-1927
Mailing Address - Country:US
Mailing Address - Phone:712-527-4811
Mailing Address - Fax:712-525-1405
Practice Address - Street 1:711 S VINE ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IA
Practice Address - Zip Code:51534-1927
Practice Address - Country:US
Practice Address - Phone:712-527-4811
Practice Address - Fax:712-525-1405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0136952OtherWAIVER