Healthcare Provider Details

I. General information

NPI: 1578841599
Provider Name (Legal Business Name): MIDWEST CARE GRANVILLE VILLA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2011
Last Update Date: 07/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8507 GRANVILLE PKWY
LA VISTA NE
68128-3212
US

IV. Provider business mailing address

8507 GRANVILLE PKWY
LA VISTA NE
68128-3212
US

V. Phone/Fax

Practice location:
  • Phone: 402-933-6405
  • Fax:
Mailing address:
  • Phone: 402-933-6405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number305S00000X
License Number StateNE

VIII. Authorized Official

Name: MR. JONATHAN MATTHEW OHLSEN-JOHNSON
Title or Position: GENERAL COUNSEL
Credential: J.D.
Phone: 541-543-1215