1821365693 NPI number — MR. VICTOR LEE GEHRIG LADC

Table of content: MR. VICTOR LEE GEHRIG LADC (NPI 1821365693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821365693 NPI number — MR. VICTOR LEE GEHRIG LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GEHRIG
Provider First Name:
VICTOR
Provider Middle Name:
LEE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LADC
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:
1821365693
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 428
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GORDON
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69343-0428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-282-1101
Provider Business Mailing Address Fax Number:
308-282-1372

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 FOCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GORDON
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69343-1709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-282-1101
Provider Business Practice Location Address Fax Number:
308-282-1372
Provider Enumeration Date:
11/22/2011

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: 101YP2500X , with the licence number:  880 , 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: 10025528800 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47073437686 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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