Healthcare Provider Details

I. General information

NPI: 1447909148
Provider Name (Legal Business Name): SIMON KABORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2633 N 165TH ST
OMAHA NE
68116-7506
US

IV. Provider business mailing address

3509 HARRISON ST
BELLEVUE NE
68147-1252
US

V. Phone/Fax

Practice location:
  • Phone: 646-546-2957
  • Fax:
Mailing address:
  • Phone: 646-546-2957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: