Provider Demographics
NPI:1396072252
Name:HANDICAP VILLAGE
Entity type:Organization
Organization Name:HANDICAP VILLAGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SEVERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-357-5277
Mailing Address - Street 1:PO BOX 622
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50428-0622
Mailing Address - Country:US
Mailing Address - Phone:641-357-5277
Mailing Address - Fax:
Practice Address - Street 1:1470 21ST AVE N
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-7114
Practice Address - Country:US
Practice Address - Phone:515-573-8243
Practice Address - Fax:515-576-4269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities