Healthcare Provider Details

I. General information

NPI: 1588503452
Provider Name (Legal Business Name): KALEB GRANDBERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 N 174TH ST
OMAHA NE
68118-2898
US

IV. Provider business mailing address

13906 GOLD CIR STE 201
OMAHA NE
68144-2336
US

V. Phone/Fax

Practice location:
  • Phone: 402-676-7229
  • Fax:
Mailing address:
  • Phone: 531-359-8428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: