Provider Demographics
NPI:1871860569
Name:WAVERLY HEALTH CENTER
Entity Type:Organization
Organization Name:WAVERLY HEALTH CENTER
Other - Org Name:SHELL ROCK CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-352-4120
Mailing Address - Street 1:312 9TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-2929
Mailing Address - Country:US
Mailing Address - Phone:319-352-4120
Mailing Address - Fax:319-352-3992
Practice Address - Street 1:1001 MASON WAY
Practice Address - Street 2:
Practice Address - City:SHELL ROCK
Practice Address - State:IA
Practice Address - Zip Code:50670-1007
Practice Address - Country:US
Practice Address - Phone:319-885-6530
Practice Address - Fax:319-885-6535
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAVERLY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-23
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
168555Medicare Oscar/Certification