=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073684239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONTY R. SELLON M.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 W 23RD ST SUITE C
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68025-2592
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-721-5727
-----------------------------------------------------
Fax | 402-753-6096
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350 W 23RD ST SUITE C
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68025-2592
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-721-5727
-----------------------------------------------------
Fax | 402-753-6096
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | DIANE VASA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 402-753-6002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 17703
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------