Provider Demographics
NPI:1215154521
Name:CHICKASAW COUNTY CARE CENTER
Entity type:Organization
Organization Name:CHICKASAW COUNTY CARE CENTER
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 1:504 SHORT AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAMPTON
Mailing Address - State:IA
Mailing Address - Zip Code:50659-1867
Mailing Address - Country:US
Mailing Address - Phone:641-394-3316
Mailing Address - Fax:641-394-5483
Practice Address - Street 1:504 SHORT AVE
Practice Address - Street 2:
Practice Address - City:NEW HAMPTON
Practice Address - State:IA
Practice Address - Zip Code:50659-1867
Practice Address - Country:US
Practice Address - Phone:641-394-3316
Practice Address - Fax:641-394-5483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAS0202310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0450056OtherELDERLY WAIVER (CDAC)