Provider Demographics
NPI:1396059051
Name:LOGAN VALLEY MANOR LLC
Entity type:Organization
Organization Name:LOGAN VALLEY MANOR LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARETT
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-296-5105
Mailing Address - Street 1:1035 DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NE
Mailing Address - Zip Code:68038-2501
Mailing Address - Country:US
Mailing Address - Phone:402-387-2636
Mailing Address - Fax:402-687-2638
Practice Address - Street 1:1035 DIAMOND ST
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NE
Practice Address - Zip Code:68038-2501
Practice Address - Country:US
Practice Address - Phone:402-687-2636
Practice Address - Fax:402-687-2638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-04
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE084001314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026103200Medicaid
NE10026103200Medicaid