Provider Demographics
NPI:1861513954
Name:CENTRAL NEBRASKA MEDICAL CLINIC AT SARGENT
Entity type:Organization
Organization Name:CENTRAL NEBRASKA MEDICAL CLINIC AT SARGENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:MINNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-872-2486
Mailing Address - Street 1:404 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SARGENT
Mailing Address - State:NE
Mailing Address - Zip Code:68874-6101
Mailing Address - Country:US
Mailing Address - Phone:308-527-4300
Mailing Address - Fax:308-527-9106
Practice Address - Street 1:404 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SARGENT
Practice Address - State:NE
Practice Address - Zip Code:68874-6101
Practice Address - Country:US
Practice Address - Phone:308-527-4300
Practice Address - Fax:308-527-9106
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL NEBRASKA MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-03
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE28D0962195OtherCLIA NUMBER
NE=========-14Medicaid
NE28D0962195OtherCLIA NUMBER