Provider Demographics
NPI:1104978055
Name:T.J. KALIES
Entity type:Organization
Organization Name:T.J. KALIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WIERICHS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-756-3344
Mailing Address - Street 1:114 N MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BRILLION
Mailing Address - State:WI
Mailing Address - Zip Code:54110
Mailing Address - Country:US
Mailing Address - Phone:920-756-3344
Mailing Address - Fax:920-756-3344
Practice Address - Street 1:114 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:BRILLION
Practice Address - State:WI
Practice Address - Zip Code:54110
Practice Address - Country:US
Practice Address - Phone:920-756-3344
Practice Address - Fax:920-756-3344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2668111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI388628200007OtherBLUE CROSS BLUE SHIELD
WI388628200007OtherBLUE CROSS BLUE SHIELD
WI=========018OtherBLUE CROSS BLUE SHIELD