Basic Information
| Provider Information | |||||||||
| NPI: | 1972608248 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAITH REGIONAL HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ST. JOSEPH'S REHABILITATION AND CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 869 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687020869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026447249 | ||||||||
| FaxNumber: | 4026447432 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 N 18TH ST | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687013686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026447375 | ||||||||
| FaxNumber: | 4023794867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 07/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DRISCOLL | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4023714880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAITH REGIONAL HEALTH SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | ALF159 | NE | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 313M00000X | 524007 | NE | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 524007 | NE | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00688 | 01 | NE | BCBS | OTHER |