Provider Demographics
NPI:1003296732
Name:GAHC3 OMAHA NE ALF TRS SUB, LLC
Entity Type:Organization
Organization Name:GAHC3 OMAHA NE ALF TRS SUB, LLC
Other - Org Name:FOUNTAIN VIEW ASSISTED LIVING AND SPECIAL MEMORY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:PROSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-270-9200
Mailing Address - Street 1:5710 S 108TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-3592
Mailing Address - Country:US
Mailing Address - Phone:402-596-9033
Mailing Address - Fax:
Practice Address - Street 1:5710 S 108TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-3592
Practice Address - Country:US
Practice Address - Phone:402-596-9033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100253886-00Medicaid