Healthcare Provider Details

I. General information

NPI: 1164593109
Provider Name (Legal Business Name): BUENA VISTA REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 W 5TH ST
STORM LAKE IA
50588-3027
US

IV. Provider business mailing address

1525 W 5TH ST PO BOX 309
STORM LAKE IA
50588-3027
US

V. Phone/Fax

Practice location:
  • Phone: 712-732-4030
  • Fax: 712-213-1233
Mailing address:
  • Phone: 712-732-4030
  • Fax: 712-213-1233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number166H
License Number StateIA

VIII. Authorized Official

Name: MRS. KRISTA L KETCHAM
Title or Position: CFO
Credential:
Phone: 712-213-8603