Basic Information
| Provider Information | |||||||||
| NPI: | 1972896611 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERIDIAN GARDENSOPERATING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4515 38TH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 686011609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025646300 | ||||||||
| FaxNumber: | 4025624594 | ||||||||
| Practice Location | |||||||||
| Address1: | 4515 38TH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | NE | ||||||||
| PostalCode: | 686011609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025646300 | ||||||||
| FaxNumber: | 4025624594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2011 | ||||||||
| LastUpdateDate: | 05/26/2011 | ||||||||
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| AuthorizedOfficialLastName: | ZEHR | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4025646300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 100254514/00 | 05 | NE | MEDICAID |