Provider Demographics
NPI:1407745243
Name:PROVIDER LLC
Entity type:Organization
Organization Name:PROVIDER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DELANAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GBEGNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-618-9786
Mailing Address - Street 1:13516 DISCOVERY DR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137
Mailing Address - Country:US
Mailing Address - Phone:502-618-9786
Mailing Address - Fax:
Practice Address - Street 1:13516 DISCOVERY DR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137
Practice Address - Country:US
Practice Address - Phone:502-618-9786
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-28
Last Update Date:2025-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities