Healthcare Provider Details

I. General information

NPI: 1396649257
Provider Name (Legal Business Name): AVERY REIGN BOSCH CPSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2609 VICTORIA AVE UNIT 646
BELLEVUE NE
68005-3067
US

IV. Provider business mailing address

2820 NW 7TH ST
LINCOLN NE
68521-4603
US

V. Phone/Fax

Practice location:
  • Phone: 402-251-3600
  • Fax:
Mailing address:
  • Phone: 402-803-8880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: