Provider Demographics
NPI:1063693166
Name:CHIROPRACTIC CARE CENTER-WAUKESHA,LLC
Entity type:Organization
Organization Name:CHIROPRACTIC CARE CENTER-WAUKESHA,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DULL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-542-9814
Mailing Address - Street 1:811 N GRANDVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2894
Mailing Address - Country:US
Mailing Address - Phone:262-542-9814
Mailing Address - Fax:262-542-9826
Practice Address - Street 1:6400 INDUSTRIAL LOOP
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:WI
Practice Address - Zip Code:53129-2452
Practice Address - Country:US
Practice Address - Phone:414-423-4100
Practice Address - Fax:414-423-4134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3572111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38920300Medicaid
WI38920300Medicaid