Basic Information
| Provider Information | |||||||||
| NPI: | 1245399302 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEARTLAND FAMILY SERVICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY SERVICE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 S 42ND ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681052909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025533000 | ||||||||
| FaxNumber: | 4025533133 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 AMERICAN PARKWAY | ||||||||
| Address2: | |||||||||
| City: | PAPILLION | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023392544 | ||||||||
| FaxNumber: | 4023394358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 09/01/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JEANETTA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 4025527402 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA, MSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 086011 | 01 | NE | MEDICARE, UNSPECIFIED | OTHER |