Provider Demographics
NPI:1265723829
Name:GRAND ISLAND COUNTRYHOUSE LLC
Entity type:Organization
Organization Name:GRAND ISLAND COUNTRYHOUSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:GLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-381-1988
Mailing Address - Street 1:833 N ALPHA ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4321
Mailing Address - Country:US
Mailing Address - Phone:308-381-1988
Mailing Address - Fax:308-381-4005
Practice Address - Street 1:833 N ALPHA ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4321
Practice Address - Country:US
Practice Address - Phone:308-381-1988
Practice Address - Fax:308-381-4005
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AGEMARK CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEALF300311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid