Provider Demographics
NPI:1780088393
Name:CLARENCE NURSING HOME, INC
Entity type:Organization
Organization Name:CLARENCE NURSING HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:TJADEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-452-3262
Mailing Address - Street 1:402 2ND AVE
Mailing Address - Street 2:PO BOX 485
Mailing Address - City:CLARENCE
Mailing Address - State:IA
Mailing Address - Zip Code:52216-9754
Mailing Address - Country:US
Mailing Address - Phone:563-452-3262
Mailing Address - Fax:563-452-3268
Practice Address - Street 1:402 2ND AVE
Practice Address - Street 2:
Practice Address - City:CLARENCE
Practice Address - State:IA
Practice Address - Zip Code:52216-9754
Practice Address - Country:US
Practice Address - Phone:563-452-3262
Practice Address - Fax:563-452-3268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0329310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA165590Medicaid