Healthcare Provider Details

I. General information

NPI: 1003613423
Provider Name (Legal Business Name): VICKIE KOMOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2025
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 DURHAM DR
PAPILLION NE
68133-2859
US

IV. Provider business mailing address

58731 289TH ST
MALVERN IA
51551-8024
US

V. Phone/Fax

Practice location:
  • Phone: 402-990-0782
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: