Healthcare Provider Details

I. General information

NPI: 1215281662
Provider Name (Legal Business Name): NOT USED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2012
Last Update Date: 11/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3219 CENTRAL AVE STE 106
KEARNEY NE
68847-2949
US

IV. Provider business mailing address

3219 CENTRAL AVE STE 106
KEARNEY NE
68847-2949
US

V. Phone/Fax

Practice location:
  • Phone: 308-865-2601
  • Fax: 308-865-2829
Mailing address:
  • Phone: 308-865-2601
  • Fax: 308-865-2829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number19175
License Number StateNE

VIII. Authorized Official

Name: DR. Z Z
Title or Position: OWNER/CEO
Credential: MD
Phone: 308-865-2601