Healthcare Provider Details

I. General information

NPI: 1619085123
Provider Name (Legal Business Name): HERITAGE OF FAIRBURY/ST EDWARD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 12/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 17TH ST
FAIRBURY NE
68352-1215
US

IV. Provider business mailing address

PO BOX 667
FAIRBURY NE
68352-0667
US

V. Phone/Fax

Practice location:
  • Phone: 402-729-2289
  • Fax: 402-729-5233
Mailing address:
  • Phone: 402-729-2289
  • Fax: 402-729-5233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number444001
License Number StateNE

VIII. Authorized Official

Name: JACK DEAN VETTER
Title or Position: PRESIDENT
Credential:
Phone: 402-895-3932