Healthcare Provider Details

I. General information

NPI: 1689922288
Provider Name (Legal Business Name): ORD SPORTS CHIROPRACTIC AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 SOUTH 16TH STREET
ORD NE
68862
US

IV. Provider business mailing address

232 SOUTH 16TH STREET
ORD NE
68862
US

V. Phone/Fax

Practice location:
  • Phone: 308-728-9986
  • Fax: 308-728-9987
Mailing address:
  • Phone: 308-728-9986
  • Fax: 308-728-9987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1720
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3678
License Number StateNE

VIII. Authorized Official

Name: DR. LUKE J STAAB
Title or Position: DOCTOR/OWNER
Credential: D.C.
Phone: 308-728-9986