NPIMap

Organization Active NPI

Providence Medical Center

  • Community Based Hospice Care Agency
  • Wayne, NE
National Provider Identifier
1639218472
Registry record updated Mar 11, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Based Hospice Care AgencyTaxonomy code 251G00000X
License
HOSPICE 29 Issued in NE
Legal business name
PROVIDENCE MEDICAL CENTER
Practice address
803 Providence Rd Ste 103
Wayne, NE 68787-1590
Phone
(402) 375-4288
NPI assigned
Feb 6, 2007
Last updated
Mar 11, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 11, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Nicole R Haglund
Title
Ceo
Phone
(402) 375-3800

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community Based Hospice Care Agency 251G00000X HOSPICE 29 NE Primary

Addresses

Primary practice location

803 Providence Rd Ste 103
Wayne, NE 68787-1590

Mailing address

1200 Providence Rd
Wayne, NE 68787-1212
Phone (402) 375-3800

Other names 1

  • Providence Hospice Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NE

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070223000269 NE Part A Provider - Hospice 4587629928 Practice locations: Wayne, NE

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1639218472. Details of each certification follow.

Hospice certification: CCN 281520

Legal name
PROVIDENCE MEDICAL CENTER
Doing business as
PROVIDENCE HOSPICE
Certification status
Active
Provider type (POS)
Hospice
Participating since
Sep 12, 1995
Last certification
Jun 11, 2021
Ownership / control type
Other
Organization structure
CorporationNon-profit
Enrollment address
803 Providence Rd
Ste 103
Wayne, NE 68787-1590

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Hospice

Medicare Care Compare
Listed as
Providence HospiceCCN 281520 · All quality measures
Ownership
Other
Certified
Sep 12, 1995
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory
Tax ID family
Providence Med Center6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 9

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Ian L Engebretsen Individual Corporate OfficerBoard Member Jan 1, 2025
Joanna Rayford Individual Corporate DirectorDirector of Hospice Oct 10, 2016
Richard Brandow Individual Corporate OfficerBoard Member - Vice Chair Jan 1, 2020
Nicole Haglund Individual Corporate DirectorInterim Ceo Jul 23, 2024
W-2 Managing EmployeeInterim Ceo Jul 23, 2024
Brittany Peters Individual Corporate Director Jan 1, 2016
Jodie Pulfer Individual Corporate OfficerBoard Member Jan 1, 2020
Kristi Fox Individual Corporate OfficerBoard Member Jan 22, 2024
Melissa Graham Individual Corporate OfficerBoard Member Jan 1, 2021
Kirby Hall Individual Corporate OfficerBoard Member Jan 1, 2025

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Providence Medical CenterWayne, NE, CCN 281345 Hospital 5% Or Greater Direct Ownership Interest (100%) Mar 2, 2010

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Affiliated clinicians 6

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170720000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1741651200000",
    "number": "1639218472",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 PROVIDENCE RD",
            "city": "WAYNE",
            "state": "NE",
            "postal_code": "687871212",
            "telephone_number": "402-375-3800",
            "fax_number": "402-375-7989"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "803 PROVIDENCE RD STE 103",
            "city": "WAYNE",
            "state": "NE",
            "postal_code": "687871590",
            "telephone_number": "402-375-4288"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-06",
        "last_updated": "2025-03-11",
        "certification_date": "2025-03-11",
        "status": "A",
        "authorized_official_last_name": "HAGLUND",
        "authorized_official_first_name": "NICOLE",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "402-375-3800"
    },
    "taxonomies": [
        {
            "code": "251G00000X",
            "taxonomy_group": "",
            "desc": "Hospice Care, Community Based",
            "state": "NE",
            "license": "HOSPICE 29",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Providence Hospice",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Wayne, NE

Sources for this page

Verify at the official NPI Registry.