Healthcare Provider Details

I. General information

NPI: 1962914549
Provider Name (Legal Business Name): TIMOTHY P HURLEY MAC, PLMHP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 11/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 W 2ND ST STE 420
GRAND ISLAND NE
68803-5468
US

IV. Provider business mailing address

2220 VIKING RD
GRAND ISLAND NE
68803-2249
US

V. Phone/Fax

Practice location:
  • Phone: 402-910-2636
  • Fax:
Mailing address:
  • Phone: 402-910-2636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number11055
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: