Healthcare Provider Details

I. General information

NPI: 1871962944
Provider Name (Legal Business Name): CHARLES DREW HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2915 GRANT ST
OMAHA NE
68111-3863
US

IV. Provider business mailing address

2915 GRANT ST
OMAHA NE
68111-3863
US

V. Phone/Fax

Practice location:
  • Phone: 402-453-1433
  • Fax: 402-457-1210
Mailing address:
  • Phone: 402-453-1433
  • Fax: 402-457-1210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNE

VIII. Authorized Official

Name: TARSHA JACKSON
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 402-457-1200