Provider Demographics
NPI:1477586139
Name:SANTA MARIANITA CLINIC, INC
Entity Type:Organization
Organization Name:SANTA MARIANITA CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RODRIGO
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ-CORDERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-379-8717
Mailing Address - Street 1:1112 VERGES AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-3853
Mailing Address - Country:US
Mailing Address - Phone:402-379-8717
Mailing Address - Fax:402-379-0447
Practice Address - Street 1:1112 VERGES AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-3853
Practice Address - Country:US
Practice Address - Phone:402-379-8717
Practice Address - Fax:402-379-0447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE15892261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE06484OtherBLUE CROSS BLUE SHIELD
NE2407OtherMIDLANDS CHOICE
NE2407OtherMIDLANDS CHOICE
NE2407OtherMIDLANDS CHOICE
NE098525Medicare PIN