Healthcare Provider Details

I. General information

NPI: 1003044660
Provider Name (Legal Business Name): CHENEY RIDGE FAMILY MEDICAL CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 VILLAGE DR SUITE 100
LINCOLN NE
68516-4706
US

IV. Provider business mailing address

3540 VILLAGE DR SUITE 100
LINCOLN NE
68516-4706
US

V. Phone/Fax

Practice location:
  • Phone: 402-420-7113
  • Fax:
Mailing address:
  • Phone: 402-420-7113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number16656
License Number StateNE

VIII. Authorized Official

Name: PATRICK J BERTOLINI
Title or Position: PRESIDENT
Credential:
Phone: 402-420-7113