Provider Demographics
NPI:1972612778
Name:HERITAGE OF WAUNETA, INC
Entity Type:Organization
Organization Name:HERITAGE OF WAUNETA, INC
Other - Org Name:HERITAGE OF WAUNETA
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 520
Mailing Address - Street 2:
Mailing Address - City:WAUNETA
Mailing Address - State:NE
Mailing Address - Zip Code:69045-0520
Mailing Address - Country:US
Mailing Address - Phone:308-394-5738
Mailing Address - Fax:308-394-5733
Practice Address - Street 1:427 W LEGION
Practice Address - Street 2:
Practice Address - City:WAUNETA
Practice Address - State:NE
Practice Address - Zip Code:69045-4549
Practice Address - Country:US
Practice Address - Phone:308-394-5738
Practice Address - Fax:308-394-5733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE134002314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE34D0664312Medicare ID - Type UnspecifiedMEDICARE CLIA WAIVER
NE285220Medicare Oscar/Certification
NE1324330001Medicare NSC
NE0454440001Medicare ID - Type UnspecifiedMEDICARE B SUPPLY