Provider Demographics
NPI:1164631214
Name:NEW VENTURE GROUP HOME
Entity type:Organization
Organization Name:NEW VENTURE GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TEMPORARY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDDLEBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:641-872-1524
Mailing Address - Street 1:401 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IA
Mailing Address - Zip Code:50060-1745
Mailing Address - Country:US
Mailing Address - Phone:641-872-1524
Mailing Address - Fax:641-872-2843
Practice Address - Street 1:401 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IA
Practice Address - Zip Code:50060-1745
Practice Address - Country:US
Practice Address - Phone:641-872-1524
Practice Address - Fax:641-872-2843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IARMR-413320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2144725HMedicaid
IA0779733EMedicaid
IA1484676DMedicaid
IA0903780CMedicaid
IA0375474DMedicaid