Provider Demographics
NPI:1922579333
Name:ELEM, KALVIN
Entity Type:Individual
Prefix:
First Name:KALVIN
Middle Name:
Last Name:ELEM
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 1:2526 N 109TH TER APT 309
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-3827
Mailing Address - Country:US
Mailing Address - Phone:531-444-0777
Mailing Address - Fax:531-444-0777
Practice Address - Street 1:2526 N 109TH TER APT 309
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-3827
Practice Address - Country:US
Practice Address - Phone:531-444-0777
Practice Address - Fax:531-444-0777
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE31989498Medicaid