=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760403612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHIROPRACTIC CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5002 CENTER ST STE 4
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-827-8879
-----------------------------------------------------
Fax | 402-884-3349
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5002 CENTER ST STE 4
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-827-8879
-----------------------------------------------------
Fax | 402-884-3349
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC DIRECTOR
-----------------------------------------------------
Name | DR. KEVIN TAM LE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 402-827-8879
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1314
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------