Provider Demographics
NPI:1740246883
Name:HAWKEYE CARE CENTER OF CRESCO LLC
Entity type:Organization
Organization Name:HAWKEYE CARE CENTER OF CRESCO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-223-0173
Mailing Address - Street 1:1912 ZENITH AVE
Mailing Address - Street 2:SUITE 2526
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360-1000
Mailing Address - Country:US
Mailing Address - Phone:712-759-1321
Mailing Address - Fax:712-759-1322
Practice Address - Street 1:701 VERNON RD
Practice Address - Street 2:
Practice Address - City:CRESCO
Practice Address - State:IA
Practice Address - Zip Code:52136-1944
Practice Address - Country:US
Practice Address - Phone:563-547-3580
Practice Address - Fax:563-547-3532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA450905314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0809467Medicaid
IA0809467Medicaid