Healthcare Provider Details

I. General information

NPI: 1043818438
Provider Name (Legal Business Name): MIBOCA 1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5305 S 96TH ST
OMAHA NE
68127-3317
US

IV. Provider business mailing address

5305 S 96TH ST
OMAHA NE
68127-3317
US

V. Phone/Fax

Practice location:
  • Phone: 402-331-0701
  • Fax: 402-331-7130
Mailing address:
  • Phone: 402-331-0701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RAFAELA MONICA ROMERO
Title or Position: MANAGER
Credential:
Phone: 402-331-0701