=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366061400
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICIANS CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2020
-----------------------------------------------------
Last Update Date | 04/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 808 EAST PIERCE STREET
-----------------------------------------------------
City | COUNCIL BLUFFS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51503-4626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-396-4360
-----------------------------------------------------
Fax | 712-396-7069
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3755
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68103-0755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-354-2100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | KERI CHARRON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 402-354-5602
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------