Healthcare Provider Details

I. General information

NPI: 1023257763
Provider Name (Legal Business Name): ENDEVEREN FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 N 90TH ST STE 1
OMAHA NE
68134-4713
US

IV. Provider business mailing address

3015 N 90TH ST STE 1
OMAHA NE
68134-4713
US

V. Phone/Fax

Practice location:
  • Phone: 402-453-6869
  • Fax: 402-961-1055
Mailing address:
  • Phone: 402-453-6869
  • Fax: 402-961-1055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22626
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22626
License Number StateNE

VIII. Authorized Official

Name: DR. NICHELLE REE HORTON-BROWN
Title or Position: SOLE MEMBER
Credential: M.D.
Phone: 402-453-6869