Basic Information
| Provider Information | |||||||||
| NPI: | 1326578956 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VSL GRAND ISLAND LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TIFFANY SQUARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20220 HARNEY ST | ||||||||
| Address2: | |||||||||
| City: | ELKHORN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680222063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028856120 | ||||||||
| FaxNumber: | 4028958165 | ||||||||
| Practice Location | |||||||||
| Address1: | 3119 W FAIDLEY AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NE | ||||||||
| PostalCode: | 688034114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3083842333 | ||||||||
| FaxNumber: | 3083843620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2017 | ||||||||
| LastUpdateDate: | 06/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | VETTER | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4028953932 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 374006 | NE | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 374006 | 01 | NE | FACILITY LICENSE | OTHER |