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General NPI Number Information
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NPI Number | 1679007249
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Entity Type | Organization
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Legal Business Name | SOUTH SIDE CONVENIENT CARE INC
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Dates
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Enumeration Date | 04/20/2017
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Last Update Date | 07/17/2023
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Provider Practice Location Address
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Address Line | 4115 HARRISON ST
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City | BELLEVUE
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State | NE
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Zip | 68147-1059
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Country | US
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Telephone | 402-932-0692
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Fax | 402-614-6731
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Provider Business Mailing Address
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Address Line | 4115 HARRISON ST
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City | BELLEVUE
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State | NE
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Zip | 68147-1059
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Country | US
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Telephone | 402-932-0692
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Fax | 402-614-6731
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Authorized Official
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Title or Position | CLINIC CREDENTIALING CONTACT
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Name | MRS. SAMANTHA SENANAYAKA
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Credential | PA-C
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Telephone | 402-350-7616
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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