MEDICARE: KALEB GRANDBERRY

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	372600000X	Adult Companion

General Provider Information

NPI Number	:	1588503452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KALEB GRANDBERRY

Provider Business Mailing Address
First Line	:	13906 GOLD CIR STE 201
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68144-2336
Country	:	US
Telephone Number	:	531-359-8428
Fax Number	:

Provider Business Practice Location Address
First Line	:	1921 N 174TH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68118-2898
Country	:	US
Telephone Number	:	402-676-7229
Fax Number	:

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

Provider Enumeration Date	:	03/26/2026
Last Update Date	:	03/26/2026

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Directions to “ KALEB GRANDBERRY ” Practice Location

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