Provider Demographics
NPI:1134149529
Name:RISEN SON CHRISTIAN VILLAGE
Entity type:Organization
Organization Name:RISEN SON CHRISTIAN VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGHEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-732-5175
Mailing Address - Street 1:3000 RISEN SON BLVD
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-1911
Mailing Address - Country:US
Mailing Address - Phone:712-366-9655
Mailing Address - Fax:712-366-4748
Practice Address - Street 1:3000 RISEN SON BLVD
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-1911
Practice Address - Country:US
Practice Address - Phone:712-366-9655
Practice Address - Fax:712-366-4748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA780641314000000X, 310400000X, 311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0808592Medicaid
IA0895557Medicaid
IA65466OtherWELLMARK BC/BS
165466Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER