=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609326982
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEITH A. ANDERSON, DC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2016
-----------------------------------------------------
Last Update Date | 10/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 238 N LINCOLN AVE
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68901-5148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-834-0666
-----------------------------------------------------
Fax | 402-834-0668
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1309 N MINNESOTA AVE
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68901-3158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-728-8118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / CHIROPRACTOR
-----------------------------------------------------
Name | KEITH A ANDERSON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 816-728-8118
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1749
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------