Healthcare Provider Details

I. General information

NPI: 1104859206
Provider Name (Legal Business Name): CITY OF GENOA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S PARK ST
GENOA NE
68640-3036
US

IV. Provider business mailing address

505 S PARK ST PO BOX 310
GENOA NE
68640-3036
US

V. Phone/Fax

Practice location:
  • Phone: 402-993-2206
  • Fax: 402-993-2595
Mailing address:
  • Phone: 402-993-2206
  • Fax: 402-993-2595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMANDA ROEBUCK
Title or Position: CEO
Credential:
Phone: 402-993-4583