Basic Information
| Provider Information | |||||||||
| NPI: | 1548482813 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVA TREATMENT COMMUNITY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8502 MORMON BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681521929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024558303 | ||||||||
| FaxNumber: | 4024557050 | ||||||||
| Practice Location | |||||||||
| Address1: | 8502 MORMON BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681521929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024558303 | ||||||||
| FaxNumber: | 4024557050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 12/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | WILSON-HINTZ | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4024558303 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100260881-00 | 05 | NE | MEDICAID |