1285719989 NPI number — COLONIAL ACRES OF HUMBOLDT

Table of content: (NPI 1285719989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285719989 NPI number — COLONIAL ACRES OF HUMBOLDT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLONIAL ACRES OF HUMBOLDT
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:
1285719989
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1043 10TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUMBOLDT
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68376-6018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-862-3123
Provider Business Mailing Address Fax Number:
402-862-2153

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1043 10TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBOLDT
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68376-6018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-862-3123
Provider Business Practice Location Address Fax Number:
402-862-2153
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOUGLAS
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
Authorized Official Title or Position:
BOARD CHAIRMAN
Authorized Official Telephone Number:
402-862-2731

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  664003 , 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: 60099 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 10025268600 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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