Provider Demographics
NPI:1235747080
Name:KWIKKEL, MARK ALLEN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:KWIKKEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 HUTTON DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:NE
Mailing Address - Zip Code:68020-2205
Mailing Address - Country:US
Mailing Address - Phone:402-349-5357
Mailing Address - Fax:
Practice Address - Street 1:310 N 10TH
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:NE
Practice Address - Zip Code:68008
Practice Address - Country:US
Practice Address - Phone:402-427-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
4023495357OtherOFFICE