Provider Demographics
NPI:1376195701
Name:KELSEY RAYMOND LLC
Entity Type:Organization
Organization Name:KELSEY RAYMOND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:LMHP
Authorized Official - Phone:402-403-9327
Mailing Address - Street 1:11725 ARBOR ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-2974
Mailing Address - Country:US
Mailing Address - Phone:402-403-9327
Mailing Address - Fax:
Practice Address - Street 1:11725 ARBOR ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2974
Practice Address - Country:US
Practice Address - Phone:402-403-9327
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEPENDINGMedicaid