Provider Demographics
NPI:1285058966
Name:RIVERSEDGE CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:RIVERSEDGE CHIROPRACTIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:PAULL
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP
Authorized Official - Phone:608-754-8977
Mailing Address - Street 1:111 N MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-3096
Mailing Address - Country:US
Mailing Address - Phone:608-754-8977
Mailing Address - Fax:608-754-8979
Practice Address - Street 1:111 N MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-3096
Practice Address - Country:US
Practice Address - Phone:608-754-8977
Practice Address - Fax:608-754-8979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4035-012111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty