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General NPI Number Information
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NPI Number | 1396059051
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Entity Type | Organization
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Legal Business Name | LOGAN VALLEY MANOR LLC
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Dates
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Enumeration Date | 08/04/2010
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Last Update Date | 01/20/2012
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Provider Practice Location Address
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Address Line | 1035 DIAMOND ST
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City | LYONS
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State | NE
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Zip | 68038-2501
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Country | US
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Telephone | 402-687-2636
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Fax | 402-687-2638
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Provider Business Mailing Address
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Address Line | 1035 DIAMOND ST
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City | LYONS
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State | NE
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Zip | 68038-2501
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Country | US
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Telephone | 402-387-2636
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Fax | 402-687-2638
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Authorized Official
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Title or Position | CEO
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Name | GARETT J ROBERTSON
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Credential |
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Telephone | 801-296-5105
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 084001
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License Number State | NE
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