Provider Demographics
NPI:1689989295
Name:EXETER CARE CENTER LLC
Entity Type:Organization
Organization Name:EXETER CARE CENTER LLC
Other - Org Name:EXETER CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARETT
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-296-5105
Mailing Address - Street 1:425 S EMPIRE AVE
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:NE
Mailing Address - Zip Code:68351-4104
Mailing Address - Country:US
Mailing Address - Phone:402-266-4501
Mailing Address - Fax:402-266-4591
Practice Address - Street 1:425 SOUTH EMPIRE AVENUE
Practice Address - Street 2:BOX 59
Practice Address - City:EXETER
Practice Address - State:NE
Practice Address - Zip Code:68351-4104
Practice Address - Country:US
Practice Address - Phone:402-266-4501
Practice Address - Fax:402-266-4591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-09
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE284001314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026103200Medicaid
NE285154Medicare Oscar/Certification