Provider Demographics
NPI:1215064597
Name:WYSOCKI, GLENN R (DC)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:R
Last Name:WYSOCKI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7537 22ND AVENUE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5701
Mailing Address - Country:US
Mailing Address - Phone:262-652-3100
Mailing Address - Fax:262-652-3100
Practice Address - Street 1:7537 22ND AVENUE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5701
Practice Address - Country:US
Practice Address - Phone:262-652-3100
Practice Address - Fax:262-652-3100
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1512111N00000X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
000075591Medicare ID - Type Unspecified