1689894958 NPI number — BUENA VISTA MANOR CARE CENTER

Table of content: (NPI 1689894958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689894958 NPI number — BUENA VISTA MANOR CARE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BUENA VISTA MANOR CARE CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689894958
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1325 LAKE AVE
Provider Second Line Business Mailing Address:
BOX 1266
Provider Business Mailing Address City Name:
STORM LAKE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50588-1907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-732-3254
Provider Business Mailing Address Fax Number:
712-732-1990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 LAKE AVE
Provider Second Line Business Practice Location Address:
BOX 1266
Provider Business Practice Location Address City Name:
STORM LAKE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50588-1907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-732-3254
Provider Business Practice Location Address Fax Number:
712-732-1990
Provider Enumeration Date:
04/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARD
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
712-732-3254

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  0478248 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0478248 . This is a "ELDERLY WAIVER RESPITE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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