Basic Information
| Provider Information | |||||||||
| NPI: | 1356425698 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINNACLE HEALTH FACILITIES XVII LP | ||||||||
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| OtherOrganizationName: | POLK CITY NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5420 W PLANO PKWY | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750934823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729313800 | ||||||||
| FaxNumber: | 9727676222 | ||||||||
| Practice Location | |||||||||
| Address1: | 1002 W WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | POLK CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502262132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159846411 | ||||||||
| FaxNumber: | 5159849294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 08/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | COLLIER | ||||||||
| AuthorizedOfficialFirstName: | JAMIE | ||||||||
| AuthorizedOfficialMiddleName: | LATTURE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 9729313800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | IA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0809848 | 05 | IA | MEDICAID |