Healthcare Provider Details

I. General information

NPI: 1528704905
Provider Name (Legal Business Name): DUECE PHALY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11011 Q ST STE 101C
OMAHA NE
68137-3700
US

IV. Provider business mailing address

825 DAVIDSON ST SE
ALBANY OR
97322-5039
US

V. Phone/Fax

Practice location:
  • Phone: 541-758-5900
  • Fax:
Mailing address:
  • Phone: 712-212-8592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: