Healthcare Provider Details

I. General information

NPI: 1689894958
Provider Name (Legal Business Name): BUENA VISTA MANOR CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 LAKE AVE BOX 1266
STORM LAKE IA
50588-1907
US

IV. Provider business mailing address

1325 LAKE AVE BOX 1266
STORM LAKE IA
50588-1907
US

V. Phone/Fax

Practice location:
  • Phone: 712-732-3254
  • Fax: 712-732-1990
Mailing address:
  • Phone: 712-732-3254
  • Fax: 712-732-1990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number0478248
License Number StateIA

VIII. Authorized Official

Name: MS. PATRICIA JEAN RICHARD
Title or Position: ADMINISTRATOR
Credential:
Phone: 712-732-3254