Provider Demographics
NPI:1073312948
Name:WAITES, KEVIN B SR
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:B
Last Name:WAITES
Suffix:SR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206 N 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68111-3847
Mailing Address - Country:US
Mailing Address - Phone:402-983-3629
Mailing Address - Fax:
Practice Address - Street 1:2206 N 28TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68111-3847
Practice Address - Country:US
Practice Address - Phone:402-983-3629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care