1356474860 NPI number — JANOVICK FAMILY CHIROPRACTIC SC

Table of content: (NPI 1356474860)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356474860 NPI number — JANOVICK FAMILY CHIROPRACTIC SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JANOVICK FAMILY CHIROPRACTIC SC
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:
1356474860
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5919 TOWER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUPERIOR
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54880-7226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-398-8803
Provider Business Mailing Address Fax Number:
715-398-8804

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5919 TOWER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUPERIOR
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54880-7226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-398-8803
Provider Business Practice Location Address Fax Number:
715-398-8804
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JANOVICK
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
MELVIN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
715-398-8803

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2851-012 , 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: 013R4JA . This is a "BCBS INDIVIDUAL NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 63I47JA . This is a "BCBS GROUP NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 38866100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2851-012 . This is a "WI LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 628822 . This is a "CHIROCARE OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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