Provider Demographics
NPI:1659337475
Name:STUART VILLAGE NURSING HOME BOARD PARKSIDE MANOR OF STUART
Entity Type:Organization
Organization Name:STUART VILLAGE NURSING HOME BOARD PARKSIDE MANOR OF STUART
Other - Org Name:PARKSIDE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:KAUP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-924-3601
Mailing Address - Street 1:PO BOX 350
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:NE
Mailing Address - Zip Code:68780-0350
Mailing Address - Country:US
Mailing Address - Phone:402-924-3601
Mailing Address - Fax:402-924-3615
Practice Address - Street 1:507 N MAIN ST
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:NE
Practice Address - Zip Code:68780-1721
Practice Address - Country:US
Practice Address - Phone:402-924-3601
Practice Address - Fax:402-924-3615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE414003314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
285245Medicare Oscar/Certification