Provider Demographics
NPI:1982082418
Name:KEOSAUQUA HEALTH CARE CENTER LLC
Entity Type:Organization
Organization Name:KEOSAUQUA HEALTH CARE CENTER LLC
Other - Org Name:KEOSAUQUA HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SORRELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-525-1114
Mailing Address - Street 1:819 COUNTRY LANE RD
Mailing Address - Street 2:
Mailing Address - City:KEOSAUQUA
Mailing Address - State:IA
Mailing Address - Zip Code:52565-1001
Mailing Address - Country:US
Mailing Address - Phone:319-293-3761
Mailing Address - Fax:319-293-3764
Practice Address - Street 1:819 COUNTRY LANE RD
Practice Address - Street 2:
Practice Address - City:KEOSAUQUA
Practice Address - State:IA
Practice Address - Zip Code:52565-1001
Practice Address - Country:US
Practice Address - Phone:319-293-3761
Practice Address - Fax:319-293-3764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-17
Last Update Date:2015-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA165204Medicare Oscar/Certification