Provider Demographics
NPI:1063563971
Name:RED CEDAR CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:RED CEDAR CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:POWELL
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-231-4994
Mailing Address - Street 1:2321 HWY 25 N.
Mailing Address - Street 2:#6
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751
Mailing Address - Country:US
Mailing Address - Phone:715-231-4994
Mailing Address - Fax:715-231-2099
Practice Address - Street 1:2321 HWY 25 N.
Practice Address - Street 2:#6
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751
Practice Address - Country:US
Practice Address - Phone:715-231-4994
Practice Address - Fax:715-231-2099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3925-012111N00000X
WI3995-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIPENDINGMedicaid
WI38732500Medicaid
WI38732500Medicaid