Healthcare Provider Details

I. General information

NPI: 1215022017
Provider Name (Legal Business Name): NEBRASKA NATIONAL GUARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 NW 24TH ST
LINCOLN NE
68524-1892
US

IV. Provider business mailing address

6905 WHITEWATER LN
LINCOLN NE
68521-8998
US

V. Phone/Fax

Practice location:
  • Phone: 402-309-1497
  • Fax:
Mailing address:
  • Phone: 402-476-7944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1102X
TaxonomyMilitary Outpatient Operational (Transportable) Component Clinic/Center
License Number57319
License Number StateNE

VIII. Authorized Official

Name: SAMANTHA S KEECH
Title or Position: DEPUTY STATE SURGEON
Credential: RN
Phone: 402-476-7944