Provider Demographics
NPI:1720746274
Name:EFEREBO, ELGIN O
Entity Type:Individual
Prefix:
First Name:ELGIN
Middle Name:O
Last Name:EFEREBO
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:PO BOX 34567
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-0567
Mailing Address - Country:US
Mailing Address - Phone:402-493-4898
Mailing Address - Fax:
Practice Address - Street 1:10910 PAUL PLZ APT 1018
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4537
Practice Address - Country:US
Practice Address - Phone:402-493-4898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026061100Medicaid