Provider Demographics
NPI:1457157620
Name:ROTH, COLBEY RUSSELL
Entity type:Individual
Prefix:
First Name:COLBEY
Middle Name:RUSSELL
Last Name:ROTH
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 1:23922 MCPHERSON AVE
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-5974
Mailing Address - Country:US
Mailing Address - Phone:402-350-0123
Mailing Address - Fax:
Practice Address - Street 1:220 N 89TH ST STE 202
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4072
Practice Address - Country:US
Practice Address - Phone:402-502-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAP67136164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse