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General NPI Number Information
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NPI Number | 1912993841
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Entity Type | Organization
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Legal Business Name | BUENA VISTA MANOR, INC.
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Dates
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Enumeration Date | 09/26/2005
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Last Update Date | 07/20/2011
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Provider Practice Location Address
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Address Line | 1325 LAKE AVE
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City | STORM LAKE
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State | IA
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Zip | 50588-1907
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Country | US
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Telephone | 712-732-3254
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Fax | 712-732-1990
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Provider Business Mailing Address
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Address Line | 1325 LAKE AVE
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City | STORM LAKE
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State | IA
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Zip | 50588-1907
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Country | US
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Telephone | 712-732-3254
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Fax | 712-732-1990
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Authorized Official
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Title or Position | GENERAL MANAGER
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Name | MR. KENNETH D. CARLSON
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Credential |
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Telephone | 515-223-6064
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | 110129
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 385H00000X
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Taxonomy Name | Respite Care
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License Number | 0478248
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License Number State | IA
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Taxonomy #3
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 165596
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License Number State | IA
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