Provider Demographics
NPI:1023257763
Name:ENDEVEREN FAMILY MEDICINE LLC
Entity type:Organization
Organization Name:ENDEVEREN FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHELLE
Authorized Official - Middle Name:REE
Authorized Official - Last Name:HORTON-BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-453-6869
Mailing Address - Street 1:3015 N 90TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-4713
Mailing Address - Country:US
Mailing Address - Phone:402-453-6869
Mailing Address - Fax:402-961-1055
Practice Address - Street 1:3015 N 90TH ST STE 1
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-4713
Practice Address - Country:US
Practice Address - Phone:402-453-6869
Practice Address - Fax:402-961-1055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22626208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEH92693Medicare UPIN