Provider Demographics
NPI:1902057185
Name:URBANDALE HEALTH CARE CENTER LLC
Entity Type:Organization
Organization Name:URBANDALE HEALTH CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-557-1190
Mailing Address - Street 1:4614 84TH ST
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-1089
Mailing Address - Country:US
Mailing Address - Phone:515-270-6838
Mailing Address - Fax:515-278-5693
Practice Address - Street 1:4614 84TH ST
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-1089
Practice Address - Country:US
Practice Address - Phone:515-270-6838
Practice Address - Fax:515-278-5693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAE726Medicaid
IA165580Medicare Oscar/Certification