Basic Information
| Provider Information | |||||||||
| NPI: | 1093070385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KALETA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 985450 NEBRASKA MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681985450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025598943 | ||||||||
| FaxNumber: | 4025595737 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 S 44TH ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681313727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025596415 | ||||||||
| FaxNumber: | 4025595737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2012 | ||||||||
| LastUpdateDate: | 07/12/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3088 | NE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 10025289000 | 05 | NE | MEDICAID |