Basic Information
| Provider Information | |||||||||
| NPI: | 1215231642 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ABBE CENTER AT ST LUKES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 11TH ST NW | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524053811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193983562 | ||||||||
| FaxNumber: | 3193983501 | ||||||||
| Practice Location | |||||||||
| Address1: | 1077 N CENTER POINT RD | ||||||||
| Address2: | |||||||||
| City: | HIAWATHA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522331231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193697952 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2010 | ||||||||
| LastUpdateDate: | 12/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | KAESTNER | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3193983562 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ABBE CENTER FOR COMMUNITY MENTAL HEALTH | ||||||||
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| AuthorizedOfficialCredential: | LISW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 0074575 | 05 | IA | MEDICAID |