Healthcare Provider Details

I. General information

NPI: 1245258292
Provider Name (Legal Business Name): KIMBERLY JOHNSON OD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 06/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 AVENUE D STE 102 B
GOTHENBURG NE
69138-1900
US

IV. Provider business mailing address

902 AVENUE D STE 102 B
GOTHENBURG NE
69138-1900
US

V. Phone/Fax

Practice location:
  • Phone: 308-537-2020
  • Fax: 308-537-2280
Mailing address:
  • Phone: 308-537-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1232
License Number StateNE

VIII. Authorized Official

Name: KIMBERLY JOHNSON
Title or Position: MEMBER
Credential: O.D.
Phone: 308-537-2020