Healthcare Provider Details

I. General information

NPI: 1639976186
Provider Name (Legal Business Name): EDGAR MOYA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 03/03/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 P AVE
KEARNEY NE
68847-4003
US

IV. Provider business mailing address

1319 E 45TH ST APT K5
KEARNEY NE
68847-4161
US

V. Phone/Fax

Practice location:
  • Phone: 308-746-3652
  • Fax:
Mailing address:
  • Phone: 308-746-3652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number73608402
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number73608402
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number73608402
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: