Healthcare Provider Details

I. General information

NPI: 1972109627
Provider Name (Legal Business Name): DAVID ICENOGLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 LEAVENWORTH ST
OMAHA NE
68105-1026
US

IV. Provider business mailing address

4001 LEAVENWORTH ST
OMAHA NE
68105-1026
US

V. Phone/Fax

Practice location:
  • Phone: 402-341-5128
  • Fax: 402-505-9803
Mailing address:
  • Phone: 402-341-5128
  • Fax: 402-505-9803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: