Healthcare Provider Details

I. General information

NPI: 1174327993
Provider Name (Legal Business Name): DISTANT LOVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2025
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6503 HAMILTON ST
OMAHA NE
68132-1252
US

IV. Provider business mailing address

6503 HAMILTON ST
OMAHA NE
68132-1252
US

V. Phone/Fax

Practice location:
  • Phone: 206-399-7012
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number State

VIII. Authorized Official

Name: MS. CASSANDRA LARAY BROWN
Title or Position: FOUNDER/ CEO
Credential:
Phone: 206-399-7012