Healthcare Provider Details

I. General information

NPI: 1235911314
Provider Name (Legal Business Name): SD HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5094 S 108TH ST
OMAHA NE
68137-2314
US

IV. Provider business mailing address

15130 BAUMAN AVE
OMAHA NE
68116-4475
US

V. Phone/Fax

Practice location:
  • Phone: 531-777-8859
  • Fax:
Mailing address:
  • Phone: 402-707-0909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code364SH0200X
TaxonomyHome Health Clinical Nurse Specialist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. TYRONE SHIELDS
Title or Position: OWNER
Credential:
Phone: 402-707-0909