Provider Demographics
NPI:1003061912
Name:GRAND ISLAND CLINIC INC
Entity Type:Organization
Organization Name:GRAND ISLAND CLINIC INC
Other - Org Name:GRAND ISLAND CLINIC INC, LAB
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:ENCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-382-1100
Mailing Address - Street 1:2444 W FAIDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4327
Mailing Address - Country:US
Mailing Address - Phone:308-382-1100
Mailing Address - Fax:308-385-0796
Practice Address - Street 1:2444 W FAIDLEY AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4327
Practice Address - Country:US
Practice Address - Phone:308-382-1100
Practice Address - Fax:308-385-0796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE28D0455760291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE087837Medicare PIN