1770611808 NPI number — CHIROPRACTIC COMPANY - MENOMONEE FALLS LTD

Table of content: ABDUL AZIZ YASIN SAMOUD (NPI 1417741539)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770611808 NPI number — CHIROPRACTIC COMPANY - MENOMONEE FALLS LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIROPRACTIC COMPANY - MENOMONEE FALLS LTD
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:
1770611808
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N96W18743 COUNTY LINE RD
Provider Second Line Business Mailing Address:
STE G
Provider Business Mailing Address City Name:
MENOMONEE FALLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53051-7100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-253-6779
Provider Business Mailing Address Fax Number:
262-253-6849

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N96W18743 COUNTY LINE RD
Provider Second Line Business Practice Location Address:
STE G
Provider Business Practice Location Address City Name:
MENOMONEE FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53051-7100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-253-6779
Provider Business Practice Location Address Fax Number:
262-253-6849
Provider Enumeration Date:
03/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CORSI
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
262-253-6779

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: 3243 , 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: 38888200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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