Healthcare Provider Details

I. General information

NPI: 1235060260
Provider Name (Legal Business Name): ELIJAH KENDALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 E 12TH ST
MC COOK NE
69001-3599
US

IV. Provider business mailing address

804 E G ST
MC COOK NE
69001-3327
US

V. Phone/Fax

Practice location:
  • Phone: 308-345-1530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: