Provider Demographics
NPI:1295058733
Name:PONCA TRIBE OF NEBRASKA
Entity type:Organization
Organization Name:PONCA TRIBE OF NEBRASKA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MISS
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:402-734-5275
Mailing Address - Street 1:2602 J ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68107-1643
Mailing Address - Country:US
Mailing Address - Phone:402-734-5275
Mailing Address - Fax:402-733-3487
Practice Address - Street 1:2602 J ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-1643
Practice Address - Country:US
Practice Address - Phone:402-734-5275
Practice Address - Fax:402-733-3487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NESATC173251S00000X
NESATC157251S00000X
NESATC174251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health