Provider Demographics
NPI:1932493822
Name:CHARLES DREW HEALTH CENTER INC
Entity Type:Organization
Organization Name:CHARLES DREW HEALTH CENTER INC
Other - Org Name:CHARLES DREW HEALTH CENTER AT CAMPUS FOR HOPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:TARSHA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-457-1215
Mailing Address - Street 1:PO BOX 30019
Mailing Address - Street 2:2915 GRANT STREET
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-1119
Mailing Address - Country:US
Mailing Address - Phone:402-451-3553
Mailing Address - Fax:402-457-1220
Practice Address - Street 1:1490 NORTH 16TH STREET
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-4118
Practice Address - Country:US
Practice Address - Phone:402-346-8401
Practice Address - Fax:402-453-2061
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLES DREW HEALTH CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-08
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101YM0800X, 261QC1500X, 261QF0400X, 363A00000X, 363LC1500X
NH261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100260951-00Medicaid