1730425059 NPI number — THE WATERFORD MEMORY CARE SOUTH 27TH, INC.

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 1730425059 NPI number — THE WATERFORD MEMORY CARE SOUTH 27TH, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE WATERFORD MEMORY CARE SOUTH 27TH, 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:
1730425059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 SW 5TH ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68522-1754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-435-3550
Provider Business Mailing Address Fax Number:
402-435-5070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8939 KEYSTONE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68516-4127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-421-8105
Provider Business Practice Location Address Fax Number:
402-421-8106
Provider Enumeration Date:
12/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KLEIN
Authorized Official First Name:
DAN
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
402-435-3550

Provider Taxonomy Codes

  • Taxonomy code: 311500000X , with the licence number:  ALF344 , 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)





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