Healthcare Provider Details

I. General information

NPI: 1396059051
Provider Name (Legal Business Name): LOGAN VALLEY MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 DIAMOND ST
LYONS NE
68038-2501
US

IV. Provider business mailing address

1035 DIAMOND ST
LYONS NE
68038-2501
US

V. Phone/Fax

Practice location:
  • Phone: 402-687-2636
  • Fax: 402-687-2638
Mailing address:
  • Phone: 402-387-2636
  • Fax: 402-687-2638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number084001
License Number StateNE

VIII. Authorized Official

Name: GARETT J ROBERTSON
Title or Position: CEO
Credential:
Phone: 801-296-5105