Provider Demographics
NPI:1619085123
Name:HERITAGE OF FAIRBURY/ST EDWARD, INC
Entity Type:Organization
Organization Name:HERITAGE OF FAIRBURY/ST EDWARD, INC
Other - Org Name:HERITAGE 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:PO BOX 667
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:NE
Mailing Address - Zip Code:68352-0667
Mailing Address - Country:US
Mailing Address - Phone:402-729-2289
Mailing Address - Fax:402-729-5233
Practice Address - Street 1:909 17TH ST
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:NE
Practice Address - Zip Code:68352-1215
Practice Address - Country:US
Practice Address - Phone:402-729-2289
Practice Address - Fax:402-729-5233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE444001314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE0581480002Medicare NSC
NE285262Medicare Oscar/Certification
NE28D0454736Medicare ID - Type UnspecifiedMEDICARE CLIA WAIVER