Provider Demographics
NPI:1124121066
Name:CHILDREN & ADOLESCENT CLINIC
Entity type:Organization
Organization Name:CHILDREN & ADOLESCENT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ZOUCHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-463-6828
Mailing Address - Street 1:2115 N KANSAS
Mailing Address - Street 2:CHILDREN & ADOLESCENT CLINIC PC
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901
Mailing Address - Country:US
Mailing Address - Phone:402-463-6828
Mailing Address - Fax:402-463-4767
Practice Address - Street 1:2115 N KANSAS
Practice Address - Street 2:CHILDREN & ADOLESCENT CLINIC PC
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901
Practice Address - Country:US
Practice Address - Phone:402-463-6828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========13Medicaid
NE096404Medicare ID - Type Unspecified