=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902776552
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AIDEN GARY BOETTCHER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2025
-----------------------------------------------------
Last Update Date | 11/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 VALLEY DR
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68787-2277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-833-1080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 16
-----------------------------------------------------
City | PLATTE
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57369-0016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-682-8746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 372600000X
-----------------------------------------------------
Taxonomy Name | Adult Companion
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------