1174824049 NPI number — BERTRAND HEALTH CLINIC, LLC

Table of content: (NPI 1174824049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174824049 NPI number — BERTRAND HEALTH CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BERTRAND HEALTH CLINIC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174824049
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
402 MINOR AVE
Provider Second Line Business Mailing Address:
PO BOX 444
Provider Business Mailing Address City Name:
BERTRAND
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68927-1234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-472-1472
Provider Business Mailing Address Fax Number:
308-472-1471

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 MINOR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERTRAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68927-1234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-472-1472
Provider Business Practice Location Address Fax Number:
308-472-1471
Provider Enumeration Date:
11/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
HOUCK
Authorized Official First Name:
RUBY
Authorized Official Middle Name:
JOAN
Authorized Official Title or Position:
OWNER OPERATOR
Authorized Official Telephone Number:
308-472-1472

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  110285 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 38615 . This is a "BLU CROSS AND BLUE SHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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