MEDICARE: STATE OF NEBRASKA DEPT OF ADMIN SERVICES

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	310400000X	Assisted Living Facility	ALF293	NE
2	314000000X	Skilled Nursing Facility	374004	NE

General Provider Information

NPI Number	:	1790706034
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF NEBRASKA DEPT OF ADMIN SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 95112
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68509-5112
Country	:	US
Telephone Number	:	402-471-1831
Fax Number	:	402-742-1142

Provider Business Practice Location Address
First Line	:	4510 E 56TH ST
Second Line	:
City	:	KEARNEY
State	:	NE
Zip	:	68847-4116
Country	:	US
Telephone Number	:	402-471-1831
Fax Number	:	402-742-1142

Authorized Official
Title or Position	:	HEALTH INFORMATION MANAGER
Name	:	CLARISSA HUNT
Credential	:
Telephone Number	:	402-471-1831

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	12/14/2018

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