1063693166 NPI number — CHIROPRACTIC CARE CENTER-WAUKESHA,LLC

Table of content: (NPI 1063693166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063693166 NPI number — CHIROPRACTIC CARE CENTER-WAUKESHA,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIROPRACTIC CARE CENTER-WAUKESHA,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:
1063693166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
811 N GRANDVIEW BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUKESHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53188-2894
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-542-9814
Provider Business Mailing Address Fax Number:
262-542-9826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6400 INDUSTRIAL LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENDALE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53129-2452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-423-4100
Provider Business Practice Location Address Fax Number:
414-423-4134
Provider Enumeration Date:
11/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DULL
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
262-542-9814

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3572 , 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)

  • Identifier: 38920300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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