Basic Information
| Provider Information | |||||||||
| NPI: | 1386941185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELGOZA | ||||||||
| FirstName: | ANGELO | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PLADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3483 LARIMORE AVE | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681112383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024558303 | ||||||||
| FaxNumber: | 4024557050 | ||||||||
| Practice Location | |||||||||
| Address1: | 3483 LARIMORE AVE | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681112383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024558303 | ||||||||
| FaxNumber: | 4024557050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2011 | ||||||||
| LastUpdateDate: | 02/15/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | P-575 | NE | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.