1619087871 NPI number — LAKE DELTON CHIROPRACTIC CLINIC LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619087871 NPI number — LAKE DELTON CHIROPRACTIC CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE DELTON CHIROPRACTIC CLINIC 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:
6
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:
1619087871
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
151 WISCONSIN DELLS PKWY S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WISCONSIN DELLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-253-0102
Provider Business Mailing Address Fax Number:
608-253-0188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 WISCONSIN DELLS PKWY S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WISCONSIN DELLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-253-0102
Provider Business Practice Location Address Fax Number:
608-253-0188
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAUER
Authorized Official First Name:
TODD
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
608-697-9994

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4029-012 , 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: 39000300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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