Healthcare Provider Details

I. General information

NPI: 1508368978
Provider Name (Legal Business Name): MIDWEST MILK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 03/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15507 EDNA ST
OMAHA NE
68138-6483
US

IV. Provider business mailing address

84150 529TH AVE
OAKDALE NE
68761-3039
US

V. Phone/Fax

Practice location:
  • Phone: 402-841-1802
  • Fax:
Mailing address:
  • Phone: 402-841-1802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-68698
License Number StateNE

VIII. Authorized Official

Name: KERRI DITTRICH
Title or Position: CO-OWNER
Credential:
Phone: 402-841-1802