Provider Demographics
NPI:1578841599
Name:MIDWEST CARE GRANVILLE VILLA LLC
Entity Type:Organization
Organization Name:MIDWEST CARE GRANVILLE VILLA LLC
Other - Org Name:GRANVILLE ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:OHLSEN-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:541-543-1215
Mailing Address - Street 1:8507 GRANVILLE PKWY
Mailing Address - Street 2:
Mailing Address - City:LA VISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-3212
Mailing Address - Country:US
Mailing Address - Phone:402-933-6405
Mailing Address - Fax:
Practice Address - Street 1:8507 GRANVILLE PKWY
Practice Address - Street 2:
Practice Address - City:LA VISTA
Practice Address - State:NE
Practice Address - Zip Code:68128-3212
Practice Address - Country:US
Practice Address - Phone:402-933-6405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE305S00000X310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025786100Medicaid