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1003310061

NPI Code Detail

MEDICARE: PINE LAKE BEHAVIORAL HEALTH, LLC.

MEDICARE: PINE LAKE BEHAVIORAL HEALTH, LLC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	333600000X	Pharmacy
3	261Q00000X	Clinic/Center		NE

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	NA3283	OTHER	NE	MEDICARE PTAN
4	DY5949	OTHER	NE	RR MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003310061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE LAKE BEHAVIORAL HEALTH, LLC.

Provider Business Mailing Address
First Line	:	9100 ANDERMATT DR STE 1
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68526-6700
Country	:	US
Telephone Number	:	402-434-2730
Fax Number	:	402-434-3970

Provider Business Practice Location Address
First Line	:	9100 ANDERMATT DRIVE SUITE 1
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68526-0000
Country	:	US
Telephone Number	:	402-434-2730
Fax Number	:	402-434-3970

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	JARED WADE RAY
Credential	:	LIPC, LADC
Telephone Number	:	402-434-2730

Provider Enumeration Date	:	03/22/2018
Last Update Date	:	02/24/2020

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Directions to “PINE LAKE BEHAVIORAL HEALTH, LLC. ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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