Provider Demographics
NPI:1770577405
Name:WAVERLEY - CASA DE PAZ, INC.
Entity type:Organization
Organization Name:WAVERLEY - CASA DE PAZ, 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 1:2121 W 19TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51103-2333
Mailing Address - Country:US
Mailing Address - Phone:712-233-3127
Mailing Address - Fax:712-258-1177
Practice Address - Street 1:2121 W 19TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51103-2333
Practice Address - Country:US
Practice Address - Phone:712-233-3127
Practice Address - Fax:712-233-1177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0474718332B00000X
IA970125314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0806919Medicaid
IA0474718OtherDME
IA0609950001OtherPART B SUPPLIER NUMBER
IA0806919Medicaid