MEDICARE: BUENA VISTA MANOR, INC.

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	385H00000X	Respite Care	0478248	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

General Provider Information

NPI Number	:	1740497403
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUENA VISTA MANOR, INC.

Provider Business Mailing Address
First Line	:	1325 LAKE AVE
Second Line	:
City	:	STORM LAKE
State	:	IA
Zip	:	50588-1907
Country	:	US
Telephone Number	:	515-233-6064
Fax Number	:	515-226-1244

Provider Business Practice Location Address
First Line	:	1325 LAKE AVE
Second Line	:
City	:	STORM LAKE
State	:	IA
Zip	:	50588-1907
Country	:	US
Telephone Number	:	515-223-6064
Fax Number	:	515-226-1244

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MR. KENNETH D. CARLSON
Credential	:
Telephone Number	:	515-223-6064

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	07/15/2011

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Directions to “BUENA VISTA MANOR, INC. ” Practice Location

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