Provider Demographics
NPI:1407964240
Name:MANOR OF LINCOLN, INC
Entity Type:Organization
Organization Name:MANOR OF LINCOLN, INC
Other - Org Name:SOUTHLAKE VILLAGE REHABILITATION AND CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:VETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-895-3932
Mailing Address - Street 1:9401 ANDERMATT DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68526-9507
Mailing Address - Country:US
Mailing Address - Phone:402-476-3274
Mailing Address - Fax:402-746-6395
Practice Address - Street 1:9401 ANDERMATT DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68526-9507
Practice Address - Country:US
Practice Address - Phone:402-476-3274
Practice Address - Fax:402-746-6395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE504010314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========Medicaid
NE28D0455351Medicare ID - Type UnspecifiedMEDICARE CLIA WAIVER
NE285219Medicare Oscar/Certification
NE0470310001Medicare NSC