Provider Demographics
NPI:1174824049
Name:BERTRAND HEALTH CLINIC, LLC
Entity Type:Organization
Organization Name:BERTRAND HEALTH CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:RUBY
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:HOUCK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:308-472-1472
Mailing Address - Street 1:402 MINOR AVE
Mailing Address - Street 2:PO BOX 444
Mailing Address - City:BERTRAND
Mailing Address - State:NE
Mailing Address - Zip Code:68927-1234
Mailing Address - Country:US
Mailing Address - Phone:308-472-1472
Mailing Address - Fax:308-472-1471
Practice Address - Street 1:402 MINOR AVE
Practice Address - Street 2:
Practice Address - City:BERTRAND
Practice Address - State:NE
Practice Address - Zip Code:68927-1234
Practice Address - Country:US
Practice Address - Phone:308-472-1472
Practice Address - Fax:308-472-1471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-09
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110285363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE38615OtherBLU CROSS AND BLUE SHIELD
NE=========00Medicaid
NE272797Medicare PIN