=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326318536
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE WATERFORD CARE FACILITY AT COLLEGE VIEW
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2012
-----------------------------------------------------
Last Update Date | 01/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4848 S 48TH ST
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68516-1290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-434-2680
-----------------------------------------------------
Fax | 402-434-2683
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4848 S 48TH ST
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68516-1290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-434-2680
-----------------------------------------------------
Fax | 402-434-2683
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | DEB MAGUIRE
-----------------------------------------------------
Credential | LPN
-----------------------------------------------------
Telephone | 402-434-2680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | ALF 076
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------