Basic Information
| Provider Information | |||||||||
| NPI: | 1790858645 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAVERLY HEALTH CENTER - AMBULANCE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | WAVERLY MUNICIPAL HOSPITAL - AMBULANCE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 9TH ST SW | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506772929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193524120 | ||||||||
| FaxNumber: | 3193528035 | ||||||||
| Practice Location | |||||||||
| Address1: | 312 9TH ST SW | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506772929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193524120 | ||||||||
| FaxNumber: | 3193528035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | TRACHTA | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3193524120 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 0044172 | 05 | IA | MEDICAID |