Basic Information
| Provider Information | |||||||||
| NPI: | 1962758979 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TR HEPBURN INC | ||||||||
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| OtherOrganizationName: | O U R HOMES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2039 Q ST | ||||||||
| Address2: | APT 101 | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685033643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024742121 | ||||||||
| FaxNumber: | 4024779752 | ||||||||
| Practice Location | |||||||||
| Address1: | 2039 Q ST | ||||||||
| Address2: | APT 101 | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685033643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024742121 | ||||||||
| FaxNumber: | 4024779752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2012 | ||||||||
| LastUpdateDate: | 05/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | HEPBURN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | FREDERICK | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER/BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4024742121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3104A0625X | ALF181 | NE | N | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness | 343900000X | B1750 | NE | N | Transportation Services | Non-emergency Medical Transport (VAN) | 390200000X | N | 193200000X MULTI-SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 3104A0625X | ALF116 | NE | Y | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 10026195600 | 05 | NE | MEDICAID | 10026240800 | 05 | NE | MEDICAID | 10026350200 | 05 | NE | MEDICAID | 10026240900 | 05 | NE | MEDICAID | 10025513400 | 05 | NE | MEDICAID | 10026241000 | 05 | NE | MEDICAID | 10026349800 | 05 | NE | MEDICAID | 10026359400 | 05 | NE | MEDICAID |