MEDICARE: DIETRICK TODD STUKENHOLTZ

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	171400000X	Health & Wellness Coach

General Provider Information

NPI Number	:	1609758903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIETRICK TODD STUKENHOLTZ

Provider Business Mailing Address
First Line	:	1340 S 64TH RD
Second Line	:
City	:	NEBRASKA CITY
State	:	NE
Zip	:	68410-6822
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1240 N 19TH ST
Second Line	:
City	:	NEBRASKA CITY
State	:	NE
Zip	:	68410-1119
Country	:	US
Telephone Number	:	402-209-3914
Fax Number	:

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

Provider Enumeration Date	:	07/25/2025
Last Update Date	:	07/25/2025

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