Healthcare Provider Details

I. General information

NPI: 1720606932
Provider Name (Legal Business Name): PHYSICIANS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 NICHOLAS ST STE 100
OMAHA NE
68114-2191
US

IV. Provider business mailing address

825 S 169TH ST
OMAHA NE
68118-9300
US

V. Phone/Fax

Practice location:
  • Phone: 402-343-1122
  • Fax: 402-343-1177
Mailing address:
  • Phone: 402-354-5451
  • Fax: 402-354-5454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TODD GRAGES
Title or Position: PRESIDENT
Credential:
Phone: 402-354-5451