Healthcare Provider Details

I. General information

NPI: 1679564496
Provider Name (Legal Business Name): WAVERLEY - MAPLE MANOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2005
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S 5TH ST
OSAGE IA
50461-1919
US

IV. Provider business mailing address

830 S 5TH ST
OSAGE IA
50461-1919
US

V. Phone/Fax

Practice location:
  • Phone: 641-732-5520
  • Fax:
Mailing address:
  • Phone: 641-732-5520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number660171
License Number StateIA

VIII. Authorized Official

Name: MR. CHAUNCEY R. DUNBAR
Title or Position: SECRETARY / TREASURER
Credential: CPA
Phone: 601-956-1576