Healthcare Provider Details

I. General information

NPI: 1750202305
Provider Name (Legal Business Name): BONIFACE NGABO NTABIMBIRWA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 S LOCUST ST
GRAND ISLAND NE
68801-8865
US

IV. Provider business mailing address

3021 S LOCUST ST
GRAND ISLAND NE
68801-8865
US

V. Phone/Fax

Practice location:
  • Phone: 515-304-0044
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: