Provider Demographics
NPI:1003613985
Name:LOLADZE, LEON
Entity type:Individual
Prefix:
First Name:LEON
Middle Name:
Last Name:LOLADZE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 S 80TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-5919
Mailing Address - Country:US
Mailing Address - Phone:615-077-0115
Mailing Address - Fax:
Practice Address - Street 1:4000 S 80TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-5919
Practice Address - Country:US
Practice Address - Phone:615-077-0115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant