Healthcare Provider Details

I. General information

NPI: 1790357861
Provider Name (Legal Business Name): CASEY FAIRCHILD MS RD LMNT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2021
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7831 CHICAGO CT
OMAHA NE
68114-3654
US

IV. Provider business mailing address

PO BOX 3755
OMAHA NE
68103-0755
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-1230
  • Fax: 402-354-1235
Mailing address:
  • Phone: 402-354-5677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1515
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: