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General NPI Number Information
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NPI Number | 1003091497
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Entity Type | Organization
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Legal Business Name | BLOOMFIELD MEDICAL CLINIC, PC
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Dates
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Enumeration Date | 01/03/2008
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Last Update Date | 03/29/2010
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Provider Practice Location Address
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Address Line | 105 S BROADWAY AVENUE
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City | BLOOMFIELD
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State | NE
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Zip | 68718-0357
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Country | US
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Telephone | 402-373-4341
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Fax | 402-373-4344
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Provider Business Mailing Address
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Address Line | 105 S BROADWAY AVENUE P O BOX 357
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City | BLOOMFIELD
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State | NE
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Zip | 68718-0357
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Country | US
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Telephone | 402-373-4341
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Fax | 402-373-4344
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Authorized Official
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Title or Position | PRESIDENT
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Name | KEVIN D LAUCK
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Credential | PA-C
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Telephone | 402-373-4341
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 110153
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 1040
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License Number State | NE
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