1942200936 NPI number — MR. RICK WAGELIE OTR/L

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942200936 NPI number — MR. RICK WAGELIE OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGELIE
Provider First Name:
RICK
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942200936
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5156 S 197TH AVENUE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68135-3679
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-290-0931
Provider Business Mailing Address Fax Number:
402-597-0382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5156 S 197TH AVENUE CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68135-3679
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-290-0931
Provider Business Practice Location Address Fax Number:
402-597-0382
Provider Enumeration Date:
07/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  # 421 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09203 . This is a "BLUE CROSS BLUE SHIELD #" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 470807419-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com