Provider Demographics
NPI:1679153217
Name:KRKELJAS, NEBOJSA NONE
Entity type:Individual
Prefix:
First Name:NEBOJSA
Middle Name:NONE
Last Name:KRKELJAS
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 1:350 N 3RD E UNIT 806
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-6536
Mailing Address - Country:US
Mailing Address - Phone:986-888-5002
Mailing Address - Fax:
Practice Address - Street 1:350 N 3RD E UNIT 806
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-6536
Practice Address - Country:US
Practice Address - Phone:986-888-5002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver