Healthcare Provider Details

I. General information

NPI: 1184638405
Provider Name (Legal Business Name): THE AMBASSADOR OMAHA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 N 72ND ST
OMAHA NE
68114-1924
US

IV. Provider business mailing address

1540 N 72ND ST
OMAHA NE
68114-1924
US

V. Phone/Fax

Practice location:
  • Phone: 402-393-6500
  • Fax:
Mailing address:
  • Phone: 402-873-8541
  • Fax: 402-873-7244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number264003
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number264003
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number264003
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number264003
License Number StateNE
# 5
Primary TaxonomyN
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number264003
License Number StateNE

VIII. Authorized Official

Name: BRENT B SHANHOLTZ
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 402-873-8541