Provider Demographics
NPI:1750412672
Name:PROFFITT'S RESIDENTIAL
Entity type:Organization
Organization Name:PROFFITT'S RESIDENTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:CATHERINE
Authorized Official - Last Name:PROFFITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-856-8344
Mailing Address - Street 1:615 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52544-1623
Mailing Address - Country:US
Mailing Address - Phone:641-856-8344
Mailing Address - Fax:641-437-4161
Practice Address - Street 1:615 WEST WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IA
Practice Address - Zip Code:52544-1623
Practice Address - Country:US
Practice Address - Phone:641-856-8344
Practice Address - Fax:641-437-4161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR542311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home