Healthcare Provider Details

I. General information

NPI: 1639401508
Provider Name (Legal Business Name): GOTHENBURG FAMILY PRACTICE RURAL HEALTH CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 20TH STREET
GOTHENBURG NE
69138-1237
US

IV. Provider business mailing address

918 20TH STREET
GOTHENBURG NE
69138-1237
US

V. Phone/Fax

Practice location:
  • Phone: 308-537-7131
  • Fax: 308-537-7310
Mailing address:
  • Phone: 308-537-7131
  • Fax: 308-537-7310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number10025929400
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GERALD E MATZKE JR.
Title or Position: PARTNER
Credential: M.D.
Phone: 308-537-7131