Healthcare Provider Details

I. General information

NPI: 1881528495
Provider Name (Legal Business Name): KRISTIN GOERTZ BERGSTROM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15655 PACIFIC ST STE 101
OMAHA NE
68118-2114
US

IV. Provider business mailing address

1655 N MAIN ST APT F
ELKHORN NE
68022-4365
US

V. Phone/Fax

Practice location:
  • Phone: 402-697-5122
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number138173
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1693
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: