=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730987728
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREIGHTON 59 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2025
-----------------------------------------------------
Last Update Date | 03/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 409 MAIN ST
-----------------------------------------------------
City | CREIGHTON
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68729-3943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-358-5699
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 220
-----------------------------------------------------
City | OSMOND
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68765-0220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-748-3661
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | TONI EMORY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 402-640-2728
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174200000X
-----------------------------------------------------
Taxonomy Name | Meals Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------