=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114065216
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PANHANDLE HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2007
-----------------------------------------------------
Last Update Date | 01/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3911 AVENUE B STE 3400
-----------------------------------------------------
City | SCOTTSBLUFF
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69361-4617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-635-8900
-----------------------------------------------------
Fax | 308-635-8920
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3911 AVENUE B STE 3400
-----------------------------------------------------
City | SCOTTSBLUFF
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69361-4617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-635-8900
-----------------------------------------------------
Fax | 308-635-8920
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC ADMINISTRATOR
-----------------------------------------------------
Name | MR. CURT COPPLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 308-630-1115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | NE22469
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------