Provider Demographics
NPI:1184917148
Name:PRAIRIE CREEK HEALTHCARE, INC.
Entity type:Organization
Organization Name:PRAIRIE CREEK HEALTHCARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MS
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:203 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:IA
Mailing Address - Zip Code:50597-5114
Mailing Address - Country:US
Mailing Address - Phone:515-887-4071
Mailing Address - Fax:515-887-3973
Practice Address - Street 1:203 4TH ST NW
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:IA
Practice Address - Zip Code:50597-5114
Practice Address - Country:US
Practice Address - Phone:515-887-4071
Practice Address - Fax:515-887-3973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-24
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA310400000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA165444Medicare Oscar/Certification