Provider Demographics
NPI:1376549972
Name:MARIAN HOME
Entity type:Organization
Organization Name:MARIAN HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRUENING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-576-5099
Mailing Address - Street 1:2400 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-3541
Mailing Address - Country:US
Mailing Address - Phone:515-576-1138
Mailing Address - Fax:515-576-5099
Practice Address - Street 1:2400 6TH AVE N
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-3541
Practice Address - Country:US
Practice Address - Phone:515-576-1138
Practice Address - Fax:515-576-5099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA940496314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0802538Medicaid
IA165539Medicare ID - Type Unspecified