Basic Information
| Provider Information | |||||||||
| NPI: | 1922683903 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COR THERAPEUTIC SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 W PASEWALK AVE STE A | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687015657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025006870 | ||||||||
| FaxNumber: | 4025006871 | ||||||||
| Practice Location | |||||||||
| Address1: | 614 N 4TH ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | ONEILL | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687631317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025006870 | ||||||||
| FaxNumber: | 4025006871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2021 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| AuthorizedOfficialLastName: | KETTLER | ||||||||
| AuthorizedOfficialFirstName: | NICKY | ||||||||
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| AuthorizedOfficialTitleorPosition: | COOWNER | ||||||||
| AuthorizedOfficialTelephone: | 4025006870 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.