Provider Demographics
NPI:1174514608
Name:WAVERLEY - IOWA, INC.
Entity type:Organization
Organization Name:WAVERLEY - IOWA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY / TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAUNCEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:DUNBAR
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:601-956-1576
Mailing Address - Street 1:1000 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:ANITA
Mailing Address - State:IA
Mailing Address - Zip Code:50020-1027
Mailing Address - Country:US
Mailing Address - Phone:712-762-3219
Mailing Address - Fax:
Practice Address - Street 1:1000 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:ANITA
Practice Address - State:IA
Practice Address - Zip Code:50020-1027
Practice Address - Country:US
Practice Address - Phone:712-762-3219
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAVERLEY-IOWA, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-03
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA150366314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0807503Medicaid
165217Medicare Oscar/Certification