=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124642863
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE BODY LAB, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2020
-----------------------------------------------------
Last Update Date | 05/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1415 DAHLBERG DR STE A
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68512-9266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 531-510-0726
-----------------------------------------------------
Fax | 420-925-7107
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1415 DAHLBERG DR STE A
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68512-9266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 531-510-0726
-----------------------------------------------------
Fax | 420-925-7107
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR/OWNER
-----------------------------------------------------
Name | DR. RACHEL HUSTON
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 308-991-8807
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------