Provider Demographics
NPI:1942200936
Name:WAGELIE, RICK (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:RICK
Middle Name:
Last Name:WAGELIE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5156 S 197TH AVENUE CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-3679
Mailing Address - Country:US
Mailing Address - Phone:402-290-0931
Mailing Address - Fax:402-597-0382
Practice Address - Street 1:5156 S 197TH AVENUE CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68135-3679
Practice Address - Country:US
Practice Address - Phone:402-290-0931
Practice Address - Fax:402-597-0382
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-30
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE# 421174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE09203OtherBLUE CROSS BLUE SHIELD #
NE470807419-00Medicaid