Healthcare Provider Details

I. General information

NPI: 1417544206
Provider Name (Legal Business Name): MIDWEST COMFORTABLE LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2020
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 S 17TH ST STE 722
OMAHA NE
68102-1911
US

IV. Provider business mailing address

811 SE 10TH LN
GRIMES IA
50111-3006
US

V. Phone/Fax

Practice location:
  • Phone: 402-378-5755
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JOQUANA GOYNES
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 515-824-2988