Provider Demographics
NPI:1912993841
Name:BUENA VISTA MANOR, INC.
Entity Type:Organization
Organization Name:BUENA VISTA MANOR, INC.
Other - Org Name:BUENA VISTA MANOR CARE CENTER INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:D
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-223-6064
Mailing Address - Street 1:1325 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-1907
Mailing Address - Country:US
Mailing Address - Phone:712-732-3254
Mailing Address - Fax:712-732-1990
Practice Address - Street 1:1325 LAKE AVE
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-1907
Practice Address - Country:US
Practice Address - Phone:712-732-3254
Practice Address - Fax:712-732-1990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA110129313M00000X
IA165596314000000X
IA0478248385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0800383Medicaid
IA16E051OtherFEDERAL PROVIDER #
16E051OtherFEDERAL SURVEY
IA165596Medicare Oscar/Certification