=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548013089
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEBRASKA TOTAL CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2024
-----------------------------------------------------
Last Update Date | 05/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7700 FORSYTH BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63105-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-206-1393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7700 FORSYTH BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63105-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT, BOARD SECRETARY
-----------------------------------------------------
Name | KENDRA ARCHER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-206-1393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------