Healthcare Provider Details

I. General information

NPI: 1386632891
Provider Name (Legal Business Name): KEITH RONALD HENTZEN RP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 MAIN ST #130
SPRINGFIELD NE
68059-3230
US

IV. Provider business mailing address

18907 WALNUT DR
GRETNA NE
68028-7238
US

V. Phone/Fax

Practice location:
  • Phone: 402-253-2000
  • Fax: 402-253-2001
Mailing address:
  • Phone: 402-332-4668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8552
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: