Healthcare Provider Details

I. General information

NPI: 1033496518
Provider Name (Legal Business Name): COUNTRY VIEW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2011
Last Update Date: 05/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 W DUNKERTON RD
WATERLOO IA
50703-9648
US

IV. Provider business mailing address

1410 W DUNKERTON RD
WATERLOO IA
50703-9648
US

V. Phone/Fax

Practice location:
  • Phone: 319-291-2509
  • Fax: 319-291-2570
Mailing address:
  • Phone: 319-291-2509
  • Fax: 319-291-2570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number070529
License Number StateIA

VIII. Authorized Official

Name: DOUGLAS C. MEYER
Title or Position: PROVISIONAL ADMINISTRATOR
Credential:
Phone: 319-291-2509