Provider Demographics
NPI:1881581114
Name:JUDEVINE, GLENN P
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:P
Last Name:JUDEVINE
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 1:14823 PAUL PLZ
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-1160
Mailing Address - Country:US
Mailing Address - Phone:402-690-8159
Mailing Address - Fax:
Practice Address - Street 1:9012 Q ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68127-3549
Practice Address - Country:US
Practice Address - Phone:402-690-8159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-19
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care