Healthcare Provider Details

I. General information

NPI: 1982845871
Provider Name (Legal Business Name): CONVALESCENT PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 03/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2915 S 74TH ST
OMAHA NE
68124-3519
US

IV. Provider business mailing address

2915 S 74TH ST
OMAHA NE
68124-3519
US

V. Phone/Fax

Practice location:
  • Phone: 402-932-8053
  • Fax:
Mailing address:
  • Phone: 402-932-8053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberALF326
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: JANETTE L MOOBERRY
Title or Position: ADMINISTRATOR
Credential:
Phone: 402-932-8053