Provider Demographics
NPI:1083602692
Name:GORDON MEMORIAL HEALTH SERVICES
Entity Type:Organization
Organization Name:GORDON MEMORIAL HEALTH SERVICES
Other - Org Name:GORDON COUNTRYSIDE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISSA
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:308-282-0806
Mailing Address - Street 1:500 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:GORDON
Mailing Address - State:NE
Mailing Address - Zip Code:69343-1157
Mailing Address - Country:US
Mailing Address - Phone:308-282-0806
Mailing Address - Fax:308-282-0251
Practice Address - Street 1:500 E 10TH ST
Practice Address - Street 2:
Practice Address - City:GORDON
Practice Address - State:NE
Practice Address - Zip Code:69343-1157
Practice Address - Country:US
Practice Address - Phone:308-282-0806
Practice Address - Fax:308-282-0251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE14261QA0600X
NEALF070310400000X
NE734001313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========11Medicaid