Provider Demographics
NPI:1962620195
Name:NORTHLAND AGENCY ON AGING
Entity type:Organization
Organization Name:NORTHLAND AGENCY ON AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUTTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-382-2941
Mailing Address - Street 1:808 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-2134
Mailing Address - Country:US
Mailing Address - Phone:563-382-2941
Mailing Address - Fax:563-382-6248
Practice Address - Street 1:808 RIVER ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2134
Practice Address - Country:US
Practice Address - Phone:563-382-2941
Practice Address - Fax:563-382-6248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0105890Medicaid