Provider Demographics
NPI:1417199092
Name:WAUKEE SENIOR HOUSING II, LLC
Entity Type:Organization
Organization Name:WAUKEE SENIOR HOUSING II, LLC
Other - Org Name:THE VILLAGE AT LEGACY POINTE NURSING FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:GARTH
Authorized Official - Last Name:EWING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-628-0073
Mailing Address - Street 1:909 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-7918
Mailing Address - Country:US
Mailing Address - Phone:641-628-0073
Mailing Address - Fax:641-620-8307
Practice Address - Street 1:1645 SE HOLIDAY CREST CIR
Practice Address - Street 2:
Practice Address - City:WAUKEE
Practice Address - State:IA
Practice Address - Zip Code:50263-8409
Practice Address - Country:US
Practice Address - Phone:515-987-3625
Practice Address - Fax:515-987-5795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA251115314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility