Basic Information
| Provider Information | |||||||||
| NPI: | 1881284602 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST CROIX NEBRASKA SIP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1065 N 115TH ST STE 120 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681544423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026094818 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1065 N 115TH ST STE 120 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681544423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026094818 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2021 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | OLSON | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6512379716 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0400X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Case Management | 164W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Licensed Practical Nurse | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RH0002X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
No ID Information.