Provider Demographics
NPI:1881704229
Name:VALENTINE MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:VALENTINE MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLIGAN-WITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-376-2200
Mailing Address - Street 1:502 N CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:VALENTINE
Mailing Address - State:NE
Mailing Address - Zip Code:69201-1518
Mailing Address - Country:US
Mailing Address - Phone:402-376-2200
Mailing Address - Fax:402-376-2219
Practice Address - Street 1:502 N CHERRY ST
Practice Address - Street 2:
Practice Address - City:VALENTINE
Practice Address - State:NE
Practice Address - Zip Code:69201-1518
Practice Address - Country:US
Practice Address - Phone:402-376-2200
Practice Address - Fax:402-376-2219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE21205261QR1300X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE=========00Medicaid