=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598906422
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVER VALLEY CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2009
-----------------------------------------------------
Last Update Date | 09/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1717 EAST 4TH STREET SUITE A
-----------------------------------------------------
City | NORTH PLATTE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69101-4392
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-534-5840
-----------------------------------------------------
Fax | 308-534-1531
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1752
-----------------------------------------------------
City | NORTH PLATTE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69103-1752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-534-5840
-----------------------------------------------------
Fax | 308-534-1531
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR/OWNER
-----------------------------------------------------
Name | MRS. KASSANDRA MARIE BERTHOLF
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 308-534-5840
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 1544
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------