Healthcare Provider Details

I. General information

NPI: 1811192479
Provider Name (Legal Business Name): MIDWEST COUNTRY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 H STREET
BURWELL NE
68823
US

IV. Provider business mailing address

HC 75 BOX 149
BASSETT NE
68714-9727
US

V. Phone/Fax

Practice location:
  • Phone: 402-684-2908
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: MELISSA DEARMONT
Title or Position: OWNER
Credential:
Phone: 402-684-2908