Healthcare Provider Details

I. General information

NPI: 1700333879
Provider Name (Legal Business Name): BROKEN BOW LIVING CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 10/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 LAUREL PKWY
BROKEN BOW NE
68822-1111
US

IV. Provider business mailing address

850 LAUREL PKWY
BROKEN BOW NE
68822-1111
US

V. Phone/Fax

Practice location:
  • Phone: 402-767-2300
  • Fax: 402-767-2800
Mailing address:
  • Phone: 402-767-2300
  • Fax: 402-767-2800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateNE

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier47042653011
Identifier TypeMEDICAID
Identifier StateNE
Identifier Issuer

VIII. Authorized Official

Name: MR. JACK VETTER
Title or Position: CEO
Credential:
Phone: 402-895-3932