Healthcare Provider Details

I. General information

NPI: 1780814475
Provider Name (Legal Business Name): PINE LAKE HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13220 CALLUM DR STE 4
WAVERLY NE
68462-2561
US

IV. Provider business mailing address

2611 S 70TH ST
LINCOLN NE
68506-2960
US

V. Phone/Fax

Practice location:
  • Phone: 402-786-5563
  • Fax: 402-423-4201
Mailing address:
  • Phone: 402-423-4200
  • Fax: 402-423-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW M GLENN
Title or Position: PHYSICIAN
Credential: MD
Phone: 402-423-4200