Provider Demographics
NPI:1417128299
Name:SACRED HEART RURAL HEALTH CLINICS
Entity Type:Organization
Organization Name:SACRED HEART RURAL HEALTH CLINICS
Other - Org Name:AVERA ONEILL FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-336-2622
Mailing Address - Street 1:403 E HYNES AVE
Mailing Address - Street 2:
Mailing Address - City:ONEILL
Mailing Address - State:NE
Mailing Address - Zip Code:68763-1301
Mailing Address - Country:US
Mailing Address - Phone:402-336-2622
Mailing Address - Fax:402-336-3240
Practice Address - Street 1:403 E HYNES AVE
Practice Address - Street 2:
Practice Address - City:ONEILL
Practice Address - State:NE
Practice Address - Zip Code:68763-1301
Practice Address - Country:US
Practice Address - Phone:402-336-2622
Practice Address - Fax:402-336-3240
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SACRED HEART HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-19
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE288508207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NECI2133Medicare PIN
NE098792Medicare PIN