Healthcare Provider Details

I. General information

NPI: 1497091888
Provider Name (Legal Business Name): BELLEVUE PRIMARY HEALTHCARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2012
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12717 S 28TH AVE
BELLEVUE NE
68123-3232
US

IV. Provider business mailing address

703 CANYON RD
BELLEVUE NE
68005-2735
US

V. Phone/Fax

Practice location:
  • Phone: 402-525-6976
  • Fax:
Mailing address:
  • Phone: 402-525-6976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number111265
License Number StateNE

VIII. Authorized Official

Name: MRS. KELLI RAE PAVLISH
Title or Position: NURSE PRACTITIONER
Credential: APRN
Phone: 402-525-6976