# PINE LAKE HEALTH LLC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** PINE LAKE HEALTH, LLC
- **Other names:** Waverly Health Care Urgent Care
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1780814475
- **Legal business name:** PINE LAKE HEALTH, LLC
- **Authorized official:** DR. MATTHEW M GLENN MD (PHYSICIAN)
- **Authorized official phone:** (402) 423-4200

## Contact information

- **Practice address:** 13220 CALLUM DR, STE 4, WAVERLY, NE 68462-2561
- **Practice address phone:** (402) 786-5563
- **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 |
| 363A00000X | Physician Assistant | — | NULL | — |
| 363A00000X | Physician Assistant | — | — | — |
| 363L00000X | Nurse Practitioner | — | NULL | — |
| 363L00000X | Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 07/16/2009
- **Last updated:** 08/30/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 10025748100 | — | NE |