Healthcare Provider Details

I. General information

NPI: 1457460230
Provider Name (Legal Business Name): HERITAGE OF ST PAUL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 HERITAGE DR
SAINT PAUL NE
68873-3618
US

IV. Provider business mailing address

1405 HERITAGE DR
SAINT PAUL NE
68873-3618
US

V. Phone/Fax

Practice location:
  • Phone: 308-754-5486
  • Fax: 308-754-5385
Mailing address:
  • Phone: 308-754-5486
  • Fax: 308-754-5385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number434001
License Number StateNE

VIII. Authorized Official

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