Healthcare Provider Details

I. General information

NPI: 1326355330
Provider Name (Legal Business Name): KENT DWAINE OLBERDING CCP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 09/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIRCLE DAVID GRANT USAF MEDICAL CENTER
APO AA
94535
US

IV. Provider business mailing address

208 HARRIS DR.
NORFOLK NE
68701
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-3735
  • Fax:
Mailing address:
  • Phone: 402-316-9760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number40
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: