Provider Demographics
NPI:1174691935
Name:FAMILY LIFE CLINIC
Entity type:Organization
Organization Name:FAMILY LIFE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ENNS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:308-236-5006
Mailing Address - Street 1:207 EAST 6TH
Mailing Address - Street 2:PO BOX 714
Mailing Address - City:LEXINGTON
Mailing Address - State:NE
Mailing Address - Zip Code:68850
Mailing Address - Country:US
Mailing Address - Phone:308-324-5623
Mailing Address - Fax:308-324-5624
Practice Address - Street 1:207 EAST 6TH
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NE
Practice Address - Zip Code:68850
Practice Address - Country:US
Practice Address - Phone:308-324-5623
Practice Address - Fax:308-324-5624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE72106H00000X
NE1071101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty