Provider Demographics
NPI:1043269780
Name:BUENA VISTA REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:BUENA VISTA REGIONAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KETCHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-213-1233
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-0309
Mailing Address - Country:US
Mailing Address - Phone:712-732-4030
Mailing Address - Fax:712-213-1233
Practice Address - Street 1:1305 W MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-2904
Practice Address - Country:US
Practice Address - Phone:712-749-2741
Practice Address - Fax:712-749-2750
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BUENA VISTA REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-09
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA67180OtherWELLMARK
IA0671800Medicaid
167180Medicare Oscar/Certification