Provider Demographics
NPI:1427119353
Name:MEDIAPOLIS CARE FACILITY INC
Entity type:Organization
Organization Name:MEDIAPOLIS CARE FACILITY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:HUTCHINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-394-3432
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:142 N ORCHARD
Mailing Address - City:MEDIAPOLIS
Mailing Address - State:IA
Mailing Address - Zip Code:52637
Mailing Address - Country:US
Mailing Address - Phone:319-394-3432
Mailing Address - Fax:319-394-3732
Practice Address - Street 1:142 N ORCHARD
Practice Address - Street 2:
Practice Address - City:MEDIAPOLIS
Practice Address - State:IA
Practice Address - Zip Code:52637
Practice Address - Country:US
Practice Address - Phone:319-394-3432
Practice Address - Fax:319-394-3732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR0360313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0894931Medicaid
IA2003358OtherIOWA ACET