Provider Demographics
NPI:1225868078
Name:SPECIALIZED OUTPATIENT SERVICES
Entity type:Organization
Organization Name:SPECIALIZED OUTPATIENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KISSACK
Authorized Official - Suffix:
Authorized Official - Credentials:LIMHP
Authorized Official - Phone:308-379-8619
Mailing Address - Street 1:1811 W 2ND STREET
Mailing Address - Street 2:SUITE 450
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803
Mailing Address - Country:US
Mailing Address - Phone:308-379-8619
Mailing Address - Fax:308-675-2690
Practice Address - Street 1:1811 W 2ND STREET
Practice Address - Street 2:SUITE 450
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803
Practice Address - Country:US
Practice Address - Phone:308-379-8619
Practice Address - Fax:308-675-2690
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECIALIZED OUTPATIENT SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health