MEDICARE: MR. KEVIN B WAITES SR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1073312948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN B WAITES SR.

Provider Business Mailing Address
First Line	:	2206 N 28TH AVE
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68111-3847
Country	:	US
Telephone Number	:	402-983-3629
Fax Number	:

Provider Business Practice Location Address
First Line	:	2206 N 28TH AVE
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68111-3847
Country	:	US
Telephone Number	:	402-983-3629
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2025
Last Update Date	:	03/12/2025

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