1326185505 NPI number — CELESTE L HEAIVILIN

Table of content: CELESTE L HEAIVILIN (NPI 1326185505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326185505 NPI number — CELESTE L HEAIVILIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEAIVILIN
Provider First Name:
CELESTE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1326185505
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
312 N ELM ST STE 108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND ISLAND
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68801-4509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-227-9271
Provider Business Mailing Address Fax Number:
308-381-7970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3180 W HIGHWAY 34
Provider Second Line Business Practice Location Address:
AHEC OFFICE
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68801-7279
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-385-6428
Provider Business Practice Location Address Fax Number:
308-385-6414
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  7068 , 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: 100251308-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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