1447483417 NPI number — BALANCE CHIROPRACTIC OF GREEN BAY, LLC

Table of content: NICOLE GUERRA WILLINGHAM LMT (NPI 1043047095)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447483417 NPI number — BALANCE CHIROPRACTIC OF GREEN BAY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALANCE CHIROPRACTIC OF GREEN BAY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447483417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3221 VOYAGER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54311-8349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-664-0047
Provider Business Mailing Address Fax Number:
920-965-1059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3221 VOYAGER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54311-8349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-664-0047
Provider Business Practice Location Address Fax Number:
920-965-1059
Provider Enumeration Date:
08/25/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KIEFERT
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
920-664-0047

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4034012 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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