1245258292 NPI number — KIMBERLY JOHNSON OD LLC

Table of content: (NPI 1245258292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245258292 NPI number — KIMBERLY JOHNSON OD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIMBERLY JOHNSON OD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1245258292
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
902 AVENUE D
Provider Second Line Business Mailing Address:
STE 102 B
Provider Business Mailing Address City Name:
GOTHENBURG
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69138-1900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-537-2020
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
902 AVENUE D
Provider Second Line Business Practice Location Address:
STE 102 B
Provider Business Practice Location Address City Name:
GOTHENBURG
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69138-1900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-537-2020
Provider Business Practice Location Address Fax Number:
308-537-2280
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
308-537-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1232 , 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: 099868 . This is a "MEDICARE GROUP PROVIDER NUMBER" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 10025277400 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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