Provider Demographics
NPI:1841313566
Name:CENTRAL NEBRASKA MEDICAL CLINIC, PC
Entity type:Organization
Organization Name:CENTRAL NEBRASKA MEDICAL CLINIC, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:MINNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-872-2486
Mailing Address - Street 1:145 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822-1378
Mailing Address - Country:US
Mailing Address - Phone:308-872-2486
Mailing Address - Fax:308-872-2027
Practice Address - Street 1:CORNER OF JEWETT AND BRIDGE
Practice Address - Street 2:
Practice Address - City:DUNNING
Practice Address - State:NE
Practice Address - Zip Code:68833-0000
Practice Address - Country:US
Practice Address - Phone:308-872-2486
Practice Address - Fax:308-872-2027
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL NEBRASKA MEDICAL CLINIC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-09
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE=========00Medicaid