Healthcare Provider Details

I. General information

NPI: 1477586139
Provider Name (Legal Business Name): SANTA MARIANITA CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 VERGES AVE
NORFOLK NE
68701-3853
US

IV. Provider business mailing address

1112 VERGES AVE
NORFOLK NE
68701-3853
US

V. Phone/Fax

Practice location:
  • Phone: 402-379-8717
  • Fax: 402-379-0447
Mailing address:
  • Phone: 402-379-8717
  • Fax: 402-379-0447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number15892
License Number StateNE

VIII. Authorized Official

Name: MR. RODRIGO GOMEZ-CORDERO
Title or Position: OWNER
Credential: M.D
Phone: 402-379-8717