Healthcare Provider Details

I. General information

NPI: 1033544267
Provider Name (Legal Business Name): 4G ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2013
Last Update Date: 09/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 S 108TH ST
OMAHA NE
68144-4802
US

IV. Provider business mailing address

2821 S 108TH ST
OMAHA NE
68144-4802
US

V. Phone/Fax

Practice location:
  • Phone: 402-933-8201
  • Fax:
Mailing address:
  • Phone: 402-933-8201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number111066
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number1737
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number22148
License Number StateNE

VIII. Authorized Official

Name: MICHELLE R MERTZ
Title or Position: OWNER
Credential:
Phone: 402-933-8201