Provider Demographics
NPI:1154620078
Name:COMPASSIONATE MEMORY CARE 1 INC
Entity type:Organization
Organization Name:COMPASSIONATE MEMORY CARE 1 INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:GRAPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-699-3761
Mailing Address - Street 1:14805 DAYTON ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-5373
Mailing Address - Country:US
Mailing Address - Phone:402-612-6789
Mailing Address - Fax:402-894-1760
Practice Address - Street 1:2402 N 102ND ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-5530
Practice Address - Country:US
Practice Address - Phone:402-391-1499
Practice Address - Fax:402-391-9774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEALF317311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100255436-00Medicaid