Healthcare Provider Details

I. General information

NPI: 1629372719
Provider Name (Legal Business Name): AVERA AT HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 MAIN ST
CREIGHTON NE
68729-3019
US

IV. Provider business mailing address

PO BOX 186
CREIGHTON NE
68729-0186
US

V. Phone/Fax

Practice location:
  • Phone: 402-358-5755
  • Fax: 402-358-5769
Mailing address:
  • Phone: 402-358-5755
  • Fax: 402-358-5769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number201404
License Number StateNE

VIII. Authorized Official

Name: MS. SANDRA D DIELEMAN
Title or Position: CEO/PRESIDENT
Credential:
Phone: 605-322-3984