Healthcare Provider Details

I. General information

NPI: 1043205578
Provider Name (Legal Business Name): KISMET OGA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 N SPRUCE ST
OGALLALA NE
69153-3307
US

IV. Provider business mailing address

1720 N SPRUCE ST
OGALLALA NE
69153-3307
US

V. Phone/Fax

Practice location:
  • Phone: 308-284-4068
  • Fax: 308-284-8381
Mailing address:
  • Phone: 308-284-4068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number474001
License Number StateNE

VIII. Authorized Official

Name: MICHAEL L. MOORE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 605-642-7736