Provider Demographics
NPI:1538235528
Name:UPPER DES MOINES OPPORTUNITY, INC
Entity type:Organization
Organization Name:UPPER DES MOINES OPPORTUNITY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FISCAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:ACCOUNTANT
Authorized Official - Phone:712-859-3885
Mailing Address - Street 1:PO BOX 519
Mailing Address - Street 2:
Mailing Address - City:GRAETTINGER
Mailing Address - State:IA
Mailing Address - Zip Code:51342-0519
Mailing Address - Country:US
Mailing Address - Phone:712-859-3885
Mailing Address - Fax:712-859-3892
Practice Address - Street 1:101 ROBINS AVE.
Practice Address - Street 2:
Practice Address - City:GRAETTINGER
Practice Address - State:IA
Practice Address - Zip Code:51342-0519
Practice Address - Country:US
Practice Address - Phone:712-859-3885
Practice Address - Fax:712-859-3892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0014613Medicaid
IA0051730Medicaid