Provider Demographics
NPI:1104049717
Name:MONTICELLO NURSING HOME COMPANY LLC
Entity type:Organization
Organization Name:MONTICELLO NURSING HOME COMPANY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHENSVOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-362-8916
Mailing Address - Street 1:502 PINEHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IA
Mailing Address - Zip Code:52310-2062
Mailing Address - Country:US
Mailing Address - Phone:319-465-2013
Mailing Address - Fax:319-465-3205
Practice Address - Street 1:502 PINEHAVEN DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IA
Practice Address - Zip Code:52310-2062
Practice Address - Country:US
Practice Address - Phone:319-465-2013
Practice Address - Fax:319-465-3205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0110310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0280636Medicaid