Provider Demographics
NPI:1457460230
Name:HERITAGE OF ST PAUL, INC
Entity Type:Organization
Organization Name:HERITAGE OF ST PAUL, INC
Other - Org Name:BROOKEFIELD PARK
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 1:1405 HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:NE
Mailing Address - Zip Code:68873-3618
Mailing Address - Country:US
Mailing Address - Phone:308-754-5486
Mailing Address - Fax:308-754-5385
Practice Address - Street 1:1405 HERITAGE DR
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:NE
Practice Address - Zip Code:68873-3618
Practice Address - Country:US
Practice Address - Phone:308-754-5486
Practice Address - Fax:308-754-5385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE434001314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE=========00Medicaid
NE3154950001Medicare NSC
NE285226Medicare Oscar/Certification