Provider Demographics
NPI:1053396218
Name:STACYVILLE COMMUNITY NURSING HOME
Entity type:Organization
Organization Name:STACYVILLE COMMUNITY NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WINEINGER
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:641-710-2215
Mailing Address - Street 1:413 S. BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:STACYVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:50476-5003
Mailing Address - Country:US
Mailing Address - Phone:641-710-2215
Mailing Address - Fax:641-710-2158
Practice Address - Street 1:413 S. BROAD STREET
Practice Address - Street 2:
Practice Address - City:STACYVILLE
Practice Address - State:IA
Practice Address - Zip Code:50476-5003
Practice Address - Country:US
Practice Address - Phone:641-710-2215
Practice Address - Fax:641-710-2158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-408311Z00000X
IA660408313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0893107Medicaid
IA0803783Medicaid
IA0893107Medicaid