1073292223 NPI number — DRIFTLESS ONE CHIROPRACTIC, INC.

Table of content: BARBARA FOGEL WAGNER CRNA (NPI 1609847953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073292223 NPI number — DRIFTLESS ONE CHIROPRACTIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRIFTLESS ONE CHIROPRACTIC, INC.
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:
1073292223
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 SUNSET RIDGE AVE STE 109
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAYS MILLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54631-8331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-542-1659
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 SUNSET RIDGE AVE STE 109
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAYS MILLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54631-8331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-542-1659
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2023

Additional Information

Authorized Official

Authorized Official Last Name:
NORDRUM
Authorized Official First Name:
KRISTOPHER
Authorized Official Middle Name:
SHANE
Authorized Official Title or Position:
CLINIC DIRECTOR/OWNER
Authorized Official Telephone Number:
630-542-1659

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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