Healthcare Provider Details

I. General information

NPI: 1710486790
Provider Name (Legal Business Name): CURTIS DANIEL SELF MA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 02/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 CALIFORNIA PLAZA
OMAHA NE
68178
US

IV. Provider business mailing address

12903 VERNON AVENUE
OMAHA NE
68164
US

V. Phone/Fax

Practice location:
  • Phone: 402-280-5554
  • Fax: 402-280-3110
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number462
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: