Provider Demographics
NPI:1912998741
Name:FRIENDSHIP HOME ASSOCIATION
Entity Type:Organization
Organization Name:FRIENDSHIP HOME ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-563-2651
Mailing Address - Street 1:714 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:AUDUBON
Mailing Address - State:IA
Mailing Address - Zip Code:50025-1362
Mailing Address - Country:US
Mailing Address - Phone:712-563-2651
Mailing Address - Fax:712-563-2342
Practice Address - Street 1:714 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:AUDUBON
Practice Address - State:IA
Practice Address - Zip Code:50025-1362
Practice Address - Country:US
Practice Address - Phone:712-563-2651
Practice Address - Fax:712-563-2342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0890160311Z00000X
IA0801316313M00000X
IA165232314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Not Answered313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0890160Medicaid
IA0801316Medicaid
IA0801316Medicaid