Provider Demographics
NPI:1174327993
Name:DISTANT LOVE
Entity type:Organization
Organization Name:DISTANT LOVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/ CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:LARAY
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-399-7012
Mailing Address - Street 1:6503 HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68132-1252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6503 HAMILTON ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68132-1252
Practice Address - Country:US
Practice Address - Phone:206-399-7012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DISTANT LOVE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty
No343800000XTransportation ServicesSecured Medical Transport (VAN)Group - Multi-Specialty
No376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty