Healthcare Provider Details

I. General information

NPI: 1801190301
Provider Name (Legal Business Name): THE INDEPENDENCE HOUSE MANDARIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2010
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 MANDARIN CIR
LINCOLN NE
68516-4434
US

IV. Provider business mailing address

1609 N ST
LINCOLN NE
68508-1884
US

V. Phone/Fax

Practice location:
  • Phone: 402-488-2755
  • Fax: 888-623-1116
Mailing address:
  • Phone: 402-475-7755
  • Fax: 402-474-2391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberALF251
License Number StateNE

VIII. Authorized Official

Name: MS. MARSHA E. STORK
Title or Position: PRESIDENT
Credential:
Phone: 402-475-7755