Basic Information
Provider Information | |||||||||
NPI: | 1437495736 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHI NATIONAL HOME CARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHI HEALTH AT HOME - GRAND ISLAND | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6281 TRI RIDGE BLVD STE 300 | ||||||||
Address2: |   | ||||||||
City: | LOVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 451408345 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5135760262 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2116 W FAIDLEY AVE | ||||||||
Address2: |   | ||||||||
City: | GRAND ISLAND | ||||||||
State: | NE | ||||||||
PostalCode: | 688034678 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3083982600 | ||||||||
FaxNumber: | 3083982633 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/14/2012 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAWKINS | ||||||||
AuthorizedOfficialFirstName: | JACK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | V.P. FINANCE & CFO | ||||||||
AuthorizedOfficialTelephone: | 5135768478 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X |   |   | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 10026348100 | 05 | NE |   | MEDICAID | 28-7005 | 01 |   | MEDICARE | OTHER |