Healthcare Provider Details

I. General information

NPI: 1285862359
Provider Name (Legal Business Name): MINNECHADUZA MEDICAL CLINIC P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 06/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 E 1ST ST SUITE 400
VALENTINE NE
69201-1802
US

IV. Provider business mailing address

148 E 1ST ST SUITE 400
VALENTINE NE
69201-1802
US

V. Phone/Fax

Practice location:
  • Phone: 402-376-1368
  • Fax: 866-614-6108
Mailing address:
  • Phone: 402-376-1368
  • Fax: 866-614-6108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4298
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number43417
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number536
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20604
License Number StateNE

VIII. Authorized Official

Name: DR. TIMOTHY W RYSCHON
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: M.D.
Phone: 402-389-2121