Healthcare Provider Details

I. General information

NPI: 1831252121
Provider Name (Legal Business Name): THE EXPRESS CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 12/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 PINE LAKE ROAD PRACTICE LOCATION 68512 PO 23048 68542
LINCOLN NE
68542
US

IV. Provider business mailing address

PO 23048
LINCOLN NE
68542
US

V. Phone/Fax

Practice location:
  • Phone: 402-420-2094
  • Fax: 402-420-2095
Mailing address:
  • Phone: 402-420-2094
  • Fax: 402-420-2095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number219844341
License Number StateNE

VIII. Authorized Official

Name: MRS. BETTE GRACE TUCKER
Title or Position: OPERATIONS MANAGER
Credential: NP
Phone: 402-423-4739