=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083284434
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHEROLYN M PRINCE DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2021
-----------------------------------------------------
Last Update Date | 06/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2650 RIVER ROAD DR
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68069-2040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-319-0801
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1611 N 214TH ST
-----------------------------------------------------
City | ELKHORN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68022-1612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-319-0801
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1864
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------