Provider Demographics
NPI:1922033273
Name:CITY OF CRAWFORD
Entity Type:Organization
Organization Name:CITY OF CRAWFORD
Other - Org Name:PONDEROSA VILLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:308-665-1224
Mailing Address - Street 1:PO BOX 526
Mailing Address - Street 2:1 PADDOCK ST
Mailing Address - City:CRAWFORD
Mailing Address - State:NE
Mailing Address - Zip Code:69339-0526
Mailing Address - Country:US
Mailing Address - Phone:308-665-1224
Mailing Address - Fax:308-665-2450
Practice Address - Street 1:1 PADDOCK ST
Practice Address - Street 2:
Practice Address - City:CRAWFORD
Practice Address - State:NE
Practice Address - Zip Code:69339-1143
Practice Address - Country:US
Practice Address - Phone:308-665-1224
Practice Address - Fax:308-665-2450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE214002314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========/00Medicaid
NE285250Medicare Oscar/Certification