Provider Demographics
NPI:1336484831
Name:ST. GREGORY RETREAT CENTERS, LLC
Entity type:Organization
Organization Name:ST. GREGORY RETREAT CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-421-4065
Mailing Address - Street 1:5875 FLEUR DR
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50321-2883
Mailing Address - Country:US
Mailing Address - Phone:515-298-7209
Mailing Address - Fax:631-410-1394
Practice Address - Street 1:5875 FLEUR DR
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50321-2883
Practice Address - Country:US
Practice Address - Phone:515-298-7209
Practice Address - Fax:631-410-1394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-10
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1332324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility