Provider Demographics
NPI:1184943797
Name:ST. JUDE RETREAT HOUSE, LLC
Entity type:Organization
Organization Name:ST. JUDE RETREAT HOUSE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-990-0340
Mailing Address - Street 1:5875 FLEUR DR
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50321-2883
Mailing Address - Country:US
Mailing Address - Phone:800-990-0340
Mailing Address - Fax:954-208-5770
Practice Address - Street 1:5875 FLEUR DR
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50321-2883
Practice Address - Country:US
Practice Address - Phone:800-990-0340
Practice Address - Fax:954-208-5770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA019302084P0800X
IAA054289363L00000X
IA1340324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0112726Medicaid