MEDICARE: WAVERLEY - CASA DE PAZ, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	0474718	IA
2	314000000X	Skilled Nursing Facility	970125	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0474718	OTHER	IA	DME
3	0609950001	OTHER	IA	PART B SUPPLIER NUMBER

General Provider Information

NPI Number	:	1770577405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAVERLEY - CASA DE PAZ, INC.

Provider Business Mailing Address
First Line	:	2121 W 19TH ST
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51103-2333
Country	:	US
Telephone Number	:	712-233-3127
Fax Number	:	712-258-1177

Provider Business Practice Location Address
First Line	:	2121 W 19TH ST
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51103-2333
Country	:	US
Telephone Number	:	712-233-3127
Fax Number	:	712-233-1177

Authorized Official
Title or Position	:	SECRETARY / TREASURER
Name	:	MR. CHAUNCEY R. DUNBAR
Credential	:	CPA
Telephone Number	:	601-956-1576

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	09/16/2008

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