Provider Demographics
NPI:1902100407
Name:THE INDEPENDENCE HOUSE SUPERIOR-AUTUMN HOUSE
Entity Type:Organization
Organization Name:THE INDEPENDENCE HOUSE SUPERIOR-AUTUMN HOUSE
Other - Org Name:EMERALD CARE COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:E
Authorized Official - Last Name:STORK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-475-7755
Mailing Address - Street 1:1609 N ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68508-1884
Mailing Address - Country:US
Mailing Address - Phone:402-475-7755
Mailing Address - Fax:402-474-2391
Practice Address - Street 1:1740 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-1502
Practice Address - Country:US
Practice Address - Phone:402-438-7844
Practice Address - Fax:888-699-1112
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMERALD CARE COMPANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-27
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEALF172311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100249578-00Medicaid