Provider Demographics
NPI:1184638405
Name:THE AMBASSADOR OMAHA, INC.
Entity Type:Organization
Organization Name:THE AMBASSADOR OMAHA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:B
Authorized Official - Last Name:SHANHOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-873-8541
Mailing Address - Street 1:1540 N 72ND ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-1924
Mailing Address - Country:US
Mailing Address - Phone:402-873-8541
Mailing Address - Fax:402-873-7244
Practice Address - Street 1:1540 N 72ND ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-1924
Practice Address - Country:US
Practice Address - Phone:402-393-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE264003225100000X, 225X00000X, 235Z00000X, 314000000X, 3140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing FacilityGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0517300002OtherDME
NE0517300002OtherDME
SD0235010Medicaid
NE=========-00Medicaid
IA0517300002OtherDME
NE=========OtherMIDLAND CHOICE
NE=========-68Medicaid
NE=========-69Medicaid
NE=========-01Medicaid
SD0235010Medicaid
NE0517300002OtherDME