Provider Demographics
NPI:1033502950
Name:NORTHEAST NEBRASKA LTC, LLC
Entity Type:Organization
Organization Name:NORTHEAST NEBRASKA LTC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:E
Authorized Official - Last Name:DEINES
Authorized Official - Suffix:
Authorized Official - Credentials:RP
Authorized Official - Phone:402-223-4779
Mailing Address - Street 1:120 N 27TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-3286
Mailing Address - Country:US
Mailing Address - Phone:402-371-3444
Mailing Address - Fax:402-371-3566
Practice Address - Street 1:120 N 27TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-3286
Practice Address - Country:US
Practice Address - Phone:402-371-3444
Practice Address - Fax:402-371-3566
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VITAL CARE PHARMACY OF NORFOLK, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6053336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy