Basic Information
| Provider Information | |||||||||
| NPI: | 1740384312 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAITH REGIONAL HEALTH SERVICES | ||||||||
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| OtherOrganizationName: | NORTHEAST NEBRASKA DIALYSIS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 869 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687020869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026447144 | ||||||||
| FaxNumber: | 4026447432 | ||||||||
| Practice Location | |||||||||
| Address1: | 1603 W PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687013683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026447592 | ||||||||
| FaxNumber: | 4026447464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 01/05/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SINEK | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4026447468 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAITH REGIONAL HEALTH SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | ESRD015 | NE | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 5530790 | 05 | SD | MEDICAID | 5000020 | 01 | NE | UNITED HEALTHCARE ESRD | OTHER | 0006400415 | 01 | NE | AETNA ESRD | OTHER | 00519 | 01 | NE | BCBS ESRD | OTHER |