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General NPI Number Information
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NPI Number | 1801518030
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Entity Type | Organization
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Legal Business Name | CONTOURBODY STRUCTURE LLC
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Dates
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Enumeration Date | 09/14/2022
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Last Update Date | 09/14/2022
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Provider Practice Location Address
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Address Line | 1515 S 204TH ST, SUITE #105
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City | ELKHORN
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State | NE
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Zip | 68022
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Country | US
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Telephone | 531-777-2752
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Fax |
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Provider Business Mailing Address
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Address Line | 2011 S 189TH CIRCLE
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City | OMAHA
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State | NE
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Zip | 68130
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | BRET VAN KETTELHUT
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Credential | MD
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Telephone | 402-253-9938
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State |
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