=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700691235
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN SPLIETHOF
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2025
-----------------------------------------------------
Last Update Date | 02/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2236 GREGG RD APT 4
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68123-4069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-425-5636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9744 MOCKINGBIRD DR
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68127-2013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-800-3787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 372600000X
-----------------------------------------------------
Taxonomy Name | Adult Companion
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------