1629105358 NPI number — SUTTON COMMUNITY HOME INC

Table of content: LISA T. WOOD LCSW (NPI 1295414423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629105358 NPI number — SUTTON COMMUNITY HOME INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUTTON COMMUNITY HOME INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629105358
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1106 N SAUNDERS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUTTON
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68979-2406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-773-5557
Provider Business Mailing Address Fax Number:
402-773-5559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 W ADA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUTTON
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68979-2520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-773-5557
Provider Business Practice Location Address Fax Number:
402-773-5559
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HORST
Authorized Official First Name:
D
Authorized Official Middle Name:
DIANNE
Authorized Official Title or Position:
NURSING HOME ADMINISTRATOR
Authorized Official Telephone Number:
402-773-5557

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  ALF235 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100250268 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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