=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689922288
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORD SPORTS CHIROPRACTIC AND WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2012
-----------------------------------------------------
Last Update Date | 08/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 232 SOUTH 16TH STREET
-----------------------------------------------------
City | ORD
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-728-9986
-----------------------------------------------------
Fax | 308-728-9987
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 232 SOUTH 16TH STREET
-----------------------------------------------------
City | ORD
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-728-9986
-----------------------------------------------------
Fax | 308-728-9987
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR/OWNER
-----------------------------------------------------
Name | DR. LUKE J STAAB
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 308-728-9986
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 3678
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1720
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------