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General NPI Number Information
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NPI Number | 1780814475
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Entity Type | Organization
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Legal Business Name | PINE LAKE HEALTH LLC
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Dates
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Enumeration Date | 07/16/2009
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Last Update Date | 08/30/2022
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Provider Practice Location Address
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Address Line | 13220 CALLUM DR STE 4
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City | WAVERLY
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State | NE
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Zip | 68462-2561
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Country | US
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Telephone | 402-786-5563
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Fax | 402-423-4201
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Provider Business Mailing Address
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Address Line | 2611 S 70TH ST
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City | LINCOLN
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State | NE
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Zip | 68506-2960
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Country | US
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Telephone | 402-423-4200
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Fax | 402-423-4201
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. MATTHEW M GLENN
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Credential | MD
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Telephone | 402-423-4200
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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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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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