Provider Demographics
NPI:1245440221
Name:INDIANOLA IA ASSISTED LIVING
Entity type:Organization
Organization Name:INDIANOLA IA ASSISTED LIVING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:GAYLA
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:GILLILAND
Authorized Official - Suffix:
Authorized Official - Credentials:MANAGER
Authorized Official - Phone:515-961-8900
Mailing Address - Street 1:608 SOUTH 15TH ST.
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50125
Mailing Address - Country:US
Mailing Address - Phone:515-961-8900
Mailing Address - Fax:515-961-8907
Practice Address - Street 1:608 SOUTH 15TH ST.
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125
Practice Address - Country:US
Practice Address - Phone:515-961-8900
Practice Address - Fax:515-961-8907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0199310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0476994Medicaid
IA1245440221Medicare PIN