Provider Demographics
NPI:1427059757
Name:KISMET IDG, LLC
Entity type:Organization
Organization Name:KISMET IDG, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-642-7736
Mailing Address - Street 1:600 MORNINGSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:IDA GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:51445-1637
Mailing Address - Country:US
Mailing Address - Phone:712-364-3327
Mailing Address - Fax:
Practice Address - Street 1:600 MORNINGSIDE AVE
Practice Address - Street 2:
Practice Address - City:IDA GROVE
Practice Address - State:IA
Practice Address - Zip Code:51445-1637
Practice Address - Country:US
Practice Address - Phone:712-364-3327
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA470912314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1427059757Medicaid
IA165206Medicare Oscar/Certification