=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922571462
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LINCOLN COUNTRYHOUSE II LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2019
-----------------------------------------------------
Last Update Date | 01/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6616 S 84TH STREET
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-421-1300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6616 S 84TH STREET
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-421-1300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | LAURA THELEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 402-421-1300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------