Basic Information
Provider Information
NPI: 1679564496
EntityType: 2
ReplacementNPI:  
OrganizationName: WAVERLEY - MAPLE MANOR, INC.
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: OSAGE REHABILITATION AND HEALTH CARE CENTER
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 830 S 5TH ST
Address2:  
City: OSAGE
State: IA
PostalCode: 504611919
CountryCode: US
TelephoneNumber: 6417325520
FaxNumber:  
Practice Location
Address1: 830 S 5TH ST
Address2:  
City: OSAGE
State: IA
PostalCode: 504611919
CountryCode: US
TelephoneNumber: 6417325520
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/01/2005
LastUpdateDate: 07/25/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: DUNBAR
AuthorizedOfficialFirstName: CHAUNCEY
AuthorizedOfficialMiddleName: R.
AuthorizedOfficialTitleorPosition: SECRETARY / TREASURER
AuthorizedOfficialTelephone: 6019561576
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: CPA
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
314000000X660171IAY Nursing & Custodial Care FacilitiesSkilled Nursing Facility 

ID Information
IDTypeStateIssuerDescription
080702405IA MEDICAID


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