Healthcare Provider Details

I. General information

NPI: 1962316646
Provider Name (Legal Business Name): TYRECE GRIGGS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2227 N 113TH ST
OMAHA NE
68164-3609
US

IV. Provider business mailing address

2227 N 113TH ST # 12
OMAHA NE
68164-3609
US

V. Phone/Fax

Practice location:
  • Phone: 402-871-4087
  • Fax:
Mailing address:
  • Phone: 402-871-4087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: