Provider Demographics
NPI:1750696852
Name:COMMUNITY NEUROREHAB OF IOWA
Entity type:Organization
Organization Name:COMMUNITY NEUROREHAB OF IOWA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:POLKOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-209-9802
Mailing Address - Street 1:3000 SW 37TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50321-1330
Mailing Address - Country:US
Mailing Address - Phone:515-288-8222
Mailing Address - Fax:
Practice Address - Street 1:3000 SW 37TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50321-1330
Practice Address - Country:US
Practice Address - Phone:515-288-8222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA771045320600000X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities