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General NPI Number Information
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NPI Number | 1851812721
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Entity Type | Organization
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Legal Business Name | RAVENNA MEDICAL CLINIC PC
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Dates
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Enumeration Date | 06/30/2017
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Last Update Date | 07/14/2017
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Provider Practice Location Address
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Address Line | 104 W SENECA ST
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City | RAVENNA
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State | NE
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Zip | 68869
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Country | US
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Telephone | 308-452-3203
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Fax | 308-452-3795
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Provider Business Mailing Address
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Address Line | 611 W SENECA ST
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City | RAVENNA
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State | NE
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Zip | 68869-1200
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Country | US
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Telephone | 308-452-3203
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Fax | 308-452-3795
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Authorized Official
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Title or Position | PHYSICIAN ASSISTANT/OWNER
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Name | RYAN LIESKE
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Credential | PA-C
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Telephone | 308-452-3203
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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