Provider Demographics
NPI:1215191093
Name:ESTELA L CHAN MD CLINIC
Entity Type:Organization
Organization Name:ESTELA L CHAN MD CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ESTELA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-746-3646
Mailing Address - Street 1:145 W 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:RED CLOUD
Mailing Address - State:NE
Mailing Address - Zip Code:68970-2542
Mailing Address - Country:US
Mailing Address - Phone:402-746-3646
Mailing Address - Fax:402-746-3519
Practice Address - Street 1:145 W 3RD AVENUE
Practice Address - Street 2:
Practice Address - City:RED CLOUD
Practice Address - State:NE
Practice Address - Zip Code:68970-2542
Practice Address - Country:US
Practice Address - Phone:402-746-3646
Practice Address - Fax:402-746-3519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE14917332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE=========00Medicaid
NE1029700001Medicare NSC
NEB67752Medicare UPIN