Provider Demographics
NPI:1386408383
Name:WAYBRIDGE PC
Entity type:Organization
Organization Name:WAYBRIDGE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOENIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-965-1371
Mailing Address - Street 1:17021 LAKESIDE HILLS PLAZA
Mailing Address - Street 2:SUITE 203
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17021 LAKESIDE HILLS PLAZA
Practice Address - Street 2:SUITE 203
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130
Practice Address - Country:US
Practice Address - Phone:402-965-1371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202D00000XAllopathic & Osteopathic PhysiciansIntegrative MedicineGroup - Single Specialty