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Organization
PINE LAKE HEALTH LLC
Active
Organization
PINE LAKE HEALTH LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MATTHEW M GLENN MD (PRESIDENT)
(402) 423-4200
Entity
Organization
Contact information
Practice address
2611 S 70TH ST, LINCOLN, NE 68506-2960
(402) 423-4200
(402) 423-4201
Mailing address
2611 S 70TH ST, LINCOLN, NE 68506-2960
(402) 423-4200
(402) 423-4201
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
NULL
207Q00000X
Family Medicine Physician
Primary
—
—
332B00000X
Durable Medical Equipment & Medical Supplies
—
NULL
363A00000X
Physician Assistant
—
NULL
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
NULL
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
02800
BCBS
NE
05
—
10025371800
—
NE
Enumeration date
05/12/2006
Last updated
08/30/2022
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