Healthcare Provider Details

I. General information

NPI: 1770988941
Provider Name (Legal Business Name): WC-GRANVILLE VILLA OPS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2014
Last Update Date: 02/06/2015
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: 402-505-9144
Mailing address:
  • Phone: 402-933-6405
  • Fax: 402-505-9144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: COLLETTE MIERES
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 402-933-6405