1912133976 NPI number — WILCOX PROPERTIES OF FORT CALHOUN, LLC

Table of content: (NPI 1912133976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912133976 NPI number — WILCOX PROPERTIES OF FORT CALHOUN, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILCOX PROPERTIES OF FORT CALHOUN, LLC
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:
AUTUMN POINTE
Provider Other Organization Name Type Code:
3
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:
1912133976
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 N 13TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT CALHOUN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68023-2054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-468-4700
Provider Business Mailing Address Fax Number:
402-468-4704

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 N 13TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT CALHOUN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68023-2054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-468-4700
Provider Business Practice Location Address Fax Number:
402-468-4704
Provider Enumeration Date:
06/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WILCOX
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
402-898-1079

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  ALF033 , 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: 10025470300 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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