Provider Demographics
NPI:1982895942
Name:COUNCIL BLUFFS COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:COUNCIL BLUFFS COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AR MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GERRI
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRUNOW
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:712-256-6577
Mailing Address - Street 1:300 WEST BROADWAY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-9040
Mailing Address - Country:US
Mailing Address - Phone:712-256-6577
Mailing Address - Fax:712-325-1932
Practice Address - Street 1:2700 COLLEGE RD
Practice Address - Street 2:A104
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-1057
Practice Address - Country:US
Practice Address - Phone:712-325-3351
Practice Address - Fax:712-325-3739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
16D0949735OtherCLIA
IA0188946Medicaid
IA=========OtherTAX ID