Provider Demographics
NPI:1487806147
Name:IVY STREET MEDICAL LLC
Entity type:Organization
Organization Name:IVY STREET MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAMGAARD
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:402-439-5500
Mailing Address - Street 1:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:NE
Mailing Address - Zip Code:68779-0047
Mailing Address - Country:US
Mailing Address - Phone:402-439-5500
Mailing Address - Fax:402-439-5502
Practice Address - Street 1:902 IVY ST
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:NE
Practice Address - Zip Code:68779-2348
Practice Address - Country:US
Practice Address - Phone:402-439-5500
Practice Address - Fax:402-439-5502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health