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General NPI Number Information
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NPI Number | 1902100407
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Entity Type | Organization
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Legal Business Name | THE INDEPENDENCE HOUSE SUPERIOR-AUTUMN HOUSE
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Dates
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Enumeration Date | 12/27/2010
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Last Update Date | 11/26/2012
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Provider Practice Location Address
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Address Line | 1740 SUPERIOR ST
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City | LINCOLN
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State | NE
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Zip | 68521-1502
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Country | US
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Telephone | 402-438-7844
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Fax | 888-699-1112
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Provider Business Mailing Address
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Address Line | 1609 N ST
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City | LINCOLN
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State | NE
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Zip | 68508-1884
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Country | US
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Telephone | 402-475-7755
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Fax | 402-474-2391
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. MARSHA E. STORK
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Credential |
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Telephone | 402-475-7755
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311500000X
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Taxonomy Name | Alzheimer Center (Dementia Center)
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License Number | ALF172
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License Number State | NE
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