Provider Demographics
NPI:1881284602
Name:ST CROIX NEBRASKA SIP LLC
Entity type:Organization
Organization Name:ST CROIX NEBRASKA SIP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-237-9716
Mailing Address - Street 1:1065 N 115TH ST STE 120
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-4423
Mailing Address - Country:US
Mailing Address - Phone:402-609-4818
Mailing Address - Fax:
Practice Address - Street 1:1065 N 115TH ST STE 120
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4423
Practice Address - Country:US
Practice Address - Phone:402-609-4818
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty