Provider Demographics
NPI:1609156520
Name:LIBERTY HOUSE WAHOO
Entity Type:Organization
Organization Name:LIBERTY HOUSE WAHOO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PINKERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-530-2688
Mailing Address - Street 1:5919 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-4101
Mailing Address - Country:US
Mailing Address - Phone:402-681-5018
Mailing Address - Fax:402-558-4700
Practice Address - Street 1:1145 N LAUREL ST
Practice Address - Street 2:
Practice Address - City:WAHOO
Practice Address - State:NE
Practice Address - Zip Code:68066-1244
Practice Address - Country:US
Practice Address - Phone:402-443-5505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEALF 298310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025480800Medicaid