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General NPI Number Information
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NPI Number | 1770577405
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Entity Type | Organization
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Legal Business Name | WAVERLEY - CASA DE PAZ, INC.
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Dates
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Enumeration Date | 09/08/2005
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Last Update Date | 09/16/2008
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Provider Practice Location Address
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Address Line | 2121 W 19TH ST
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City | SIOUX CITY
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State | IA
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Zip | 51103-2333
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Country | US
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Telephone | 712-233-3127
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Fax | 712-233-1177
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Provider Business Mailing Address
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Address Line | 2121 W 19TH ST
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City | SIOUX CITY
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State | IA
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Zip | 51103-2333
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Country | US
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Telephone | 712-233-3127
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Fax | 712-258-1177
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Authorized Official
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Title or Position | SECRETARY / TREASURER
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Name | MR. CHAUNCEY R. DUNBAR
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Credential | CPA
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Telephone | 601-956-1576
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 0474718
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 970125
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License Number State | IA
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