Basic Information
| Provider Information | |||||||||
| NPI: | 1801452057 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAITH REGIONAL HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 869 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687020869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026447249 | ||||||||
| FaxNumber: | 4026447432 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 W NORFOLK AVE | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687014438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028448299 | ||||||||
| FaxNumber: | 4026447267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2019 | ||||||||
| LastUpdateDate: | 05/14/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILKER | ||||||||
| AuthorizedOfficialFirstName: | JOHNATHAN | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4026447249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAITH REGIONAL HEALTH SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
No ID Information.