1447091004 NPI number — STATE OF NEBRASKA DEPT OF ADMIN SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447091004 NPI number — STATE OF NEBRASKA DEPT OF ADMIN SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF NEBRASKA DEPT OF ADMIN SERVICES
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:
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:
1447091004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2610 N 20TH ST E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-522-7136
Provider Business Mailing Address Fax Number:
402-595-2822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2610 N 20TH ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-522-7136
Provider Business Practice Location Address Fax Number:
402-595-2822
Provider Enumeration Date:
06/05/2024

Additional Information

Authorized Official

Authorized Official Last Name:
PUTNAM
Authorized Official First Name:
CASSANDRA
Authorized Official Middle Name:
JANE
Authorized Official Title or Position:
HEALTH CARE ADMINISTRATOR
Authorized Official Telephone Number:
402-479-5630

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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