MEDICARE: COUNTY OF BLACKHAWK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	070529	IA
2	314000000X	Skilled Nursing Facility	070529	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346245347
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTY OF BLACKHAWK

Provider Business Mailing Address
First Line	:	1410 W DUNKERTON RD
Second Line	:
City	:	WATERLOO
State	:	IA
Zip	:	50703-9648
Country	:	US
Telephone Number	:	319-291-2509
Fax Number	:	319-291-2570

Provider Business Practice Location Address
First Line	:	1410 W DUNKERTON RD
Second Line	:
City	:	WATERLOO
State	:	IA
Zip	:	50703-9648
Country	:	US
Telephone Number	:	319-291-2509
Fax Number	:	319-291-2570

Authorized Official
Title or Position	:	PROVISIONAL ADMINISTRATOR
Name	:	DOUGLAS C. MEYER
Credential	:
Telephone Number	:	319-291-2509

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	05/10/2013

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Directions to “COUNTY OF BLACKHAWK ” Practice Location

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