Healthcare Provider Details

I. General information

NPI: 1568942803
Provider Name (Legal Business Name): CHILDREN & ADOLESEANT CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 N KANSAS AVE STE 103
HASTINGS NE
68901-2615
US

IV. Provider business mailing address

2115 N KANSAS AVE STE 103
HASTINGS NE
68901-2615
US

V. Phone/Fax

Practice location:
  • Phone: 402-463-6728
  • Fax: 402-463-4767
Mailing address:
  • Phone: 402-463-6728
  • Fax: 402-463-4767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW UTECHT
Title or Position: ADMINISTRATOR
Credential:
Phone: 402-463-6828