Healthcare Provider Details

I. General information

NPI: 1770577405
Provider Name (Legal Business Name): WAVERLEY - CASA DE PAZ, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 W 19TH ST
SIOUX CITY IA
51103-2333
US

IV. Provider business mailing address

2121 W 19TH ST
SIOUX CITY IA
51103-2333
US

V. Phone/Fax

Practice location:
  • Phone: 712-233-3127
  • Fax: 712-233-1177
Mailing address:
  • Phone: 712-233-3127
  • Fax: 712-258-1177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number970125
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0474718
License Number StateIA

VIII. Authorized Official

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