Provider Demographics
NPI:1750630661
Name:CALLAWAY GOOD LIFE CENTER INC
Entity Type:Organization
Organization Name:CALLAWAY GOOD LIFE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:JORGENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-380-0335
Mailing Address - Street 1:308 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CALLAWAY
Mailing Address - State:NE
Mailing Address - Zip Code:68825-5124
Mailing Address - Country:US
Mailing Address - Phone:308-380-0335
Mailing Address - Fax:
Practice Address - Street 1:600 W KIMBALL ST
Practice Address - Street 2:
Practice Address - City:CALLAWAY
Practice Address - State:NE
Practice Address - Zip Code:68825-2592
Practice Address - Country:US
Practice Address - Phone:308-380-0335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-06
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD285200Medicare Oscar/Certification