Provider Demographics
NPI:1679527840
Name:SCOTTISH RITE PARK, INC.
Entity type:Organization
Organization Name:SCOTTISH RITE PARK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-202-2010
Mailing Address - Street 1:2909 WOODLAND AVE.
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312
Mailing Address - Country:US
Mailing Address - Phone:515-274-4614
Mailing Address - Fax:515-274-6049
Practice Address - Street 1:2909 WOODLAND AVE.
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312
Practice Address - Country:US
Practice Address - Phone:515-274-4614
Practice Address - Fax:515-274-6049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA770155313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA16D0912082OtherCLIA
IA770155OtherIA LICENSE #
IA0800022Medicaid
IA0800022Medicaid