Basic Information
| Provider Information | |||||||||
| NPI: | 1952852030 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHI HEALTH CLINIC SPECIALTY, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GOOD LIFE BIRTH PLACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7440 S 91ST ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685269797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024210904 | ||||||||
| FaxNumber: | 4024210946 | ||||||||
| Practice Location | |||||||||
| Address1: | 8020 O ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685102561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024886370 | ||||||||
| FaxNumber: | 4024884393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2016 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JANKUSKI | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4024343474 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALEGENT CREIGHTON CLINIC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QB0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Birthing |
No ID Information.