Healthcare Provider Details

I. General information

NPI: 1629884523
Provider Name (Legal Business Name): PGFHGS HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3506 S 201ST CIR
OMAHA NE
68130-5094
US

IV. Provider business mailing address

3506 S 201ST CIR
OMAHA NE
68130-5094
US

V. Phone/Fax

Practice location:
  • Phone: 402-681-4030
  • Fax:
Mailing address:
  • Phone: 402-681-4030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: GABRIEL MICHAEL SULLIVAN
Title or Position: OWNER
Credential:
Phone: 402-681-4030