Provider Demographics
NPI:1033648274
Name:CREEKSIDE AT ELFINDALE
Entity Type:Organization
Organization Name:CREEKSIDE AT ELFINDALE
Other - Org Name:CREEKSIDE AT ELFINDALE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:D
Authorized Official - Last Name:VETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-895-3932
Mailing Address - Street 1:20220 HARNEY ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-2063
Mailing Address - Country:US
Mailing Address - Phone:402-885-6120
Mailing Address - Fax:402-895-8165
Practice Address - Street 1:1601 S FORT AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-8430
Practice Address - Country:US
Practice Address - Phone:417-831-3828
Practice Address - Fax:417-831-3899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-10
Last Update Date:2017-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOBUS-0017337310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility