Provider Demographics
NPI:1871949024
Name:HILLCREST SHADOW LAKE LLC
Entity type:Organization
Organization Name:HILLCREST SHADOW LAKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JOLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-682-4800
Mailing Address - Street 1:1902 HARLAN DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-6609
Mailing Address - Country:US
Mailing Address - Phone:402-682-4800
Mailing Address - Fax:
Practice Address - Street 1:1507 E GOLD COAST RD
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-4722
Practice Address - Country:US
Practice Address - Phone:402-682-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-06
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026587800Medicaid