Healthcare Provider Details

I. General information

NPI: 1003091497
Provider Name (Legal Business Name): BLOOMFIELD MEDICAL CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 03/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S BROADWAY AVENUE
BLOOMFIELD NE
68718-0357
US

IV. Provider business mailing address

105 S BROADWAY AVENUE P O BOX 357
BLOOMFIELD NE
68718-0357
US

V. Phone/Fax

Practice location:
  • Phone: 402-373-4341
  • Fax: 402-373-4344
Mailing address:
  • Phone: 402-373-4341
  • Fax: 402-373-4344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number110153
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1040
License Number StateNE

VIII. Authorized Official

Name: KEVIN D LAUCK
Title or Position: PRESIDENT
Credential: PA-C
Phone: 402-373-4341