1578172110 NPI number — KELSEY ROSE GREGERSON MOT, OTR/L

Table of content: KELSEY ROSE GREGERSON MOT, OTR/L (NPI 1578172110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578172110 NPI number — KELSEY ROSE GREGERSON MOT, OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREGERSON
Provider First Name:
KELSEY
Provider Middle Name:
ROSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MOT, OTR/L
Provider Gender Code:
F

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:
1578172110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 S 186TH PLZ APT 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKHORN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68022-5402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-536-0484
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20650 GLENN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKHORN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68022-2324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-289-2579
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2020

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: 225X00000X , with the licence number:  2382 , 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)





Copyright © 2007-2025 www.npivalidator.com