MEDICARE: OMAHA NATIVE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1306451315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMAHA NATIVE LLC

Provider Business Mailing Address
First Line	:	3610 N 163RD PLZ # 101
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68116-2164
Country	:	US
Telephone Number	:	402-359-1996
Fax Number	:

Provider Business Practice Location Address
First Line	:	3610 N 163RD PLZ # 101
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68116-2164
Country	:	US
Telephone Number	:	402-359-1996
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	RYAN MATTHEW GRAY
Credential	:
Telephone Number	:	402-359-1996

Provider Enumeration Date	:	09/15/2020
Last Update Date	:	09/15/2020

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Directions to “OMAHA NATIVE LLC ” Practice Location

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