# PINE LAKE HEALTH LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1417908666
- **Authorized official:** MR. MATTHEW M GLENN MD (PRESIDENT)
- **Authorized official phone:** (402) 423-4200

## Contact information

- **Practice address:** 2611 S 70TH ST, LINCOLN, NE 68506-2960
- **Practice address phone:** (402) 423-4200
- **Practice address fax:** (402) 423-4201
- **Mailing address:** 2611 S 70TH ST, LINCOLN, NE 68506-2960
- **Mailing address phone:** (402) 423-4200
- **Mailing address fax:** (402) 423-4201

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 332B00000X | Durable Medical Equipment & Medical Supplies | — | NULL | — |
| 363A00000X | Physician Assistant | — | NULL | — |
| 363A00000X | Physician Assistant | — | — | — |
| 363L00000X | Nurse Practitioner | — | NULL | — |
| 363L00000X | Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 05/12/2006
- **Last updated:** 08/30/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 02800 | BCBS | NE |
| 05 | — | 10025371800 | — | NE |