Provider Demographics
NPI:1801518030
Name:CONTOURBODY STRUCTURE LLC
Entity type:Organization
Organization Name:CONTOURBODY STRUCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRET
Authorized Official - Middle Name:VAN
Authorized Official - Last Name:KETTELHUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-253-9938
Mailing Address - Street 1:2011 S 189TH CIRCLE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1515 S 204TH ST, SUITE #105
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022
Practice Address - Country:US
Practice Address - Phone:531-777-2752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty