=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033340146
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUFFS HEALTH CARE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2009
-----------------------------------------------------
Last Update Date | 08/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 914 W 36TH STR
-----------------------------------------------------
City | SCOTTSBLUFF
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-633-1280
-----------------------------------------------------
Fax | 308-633-1285
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 914 W 36TH STR
-----------------------------------------------------
City | SCOTTSBLUFF
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-633-1280
-----------------------------------------------------
Fax | 308-633-1285
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN ASSISTANT
-----------------------------------------------------
Name | STEPHEN E. VAN NOY
-----------------------------------------------------
Credential | PA-C, MPAS
-----------------------------------------------------
Telephone | 308-633-1280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 875
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------