Provider Demographics
NPI:1285700955
Name:DALE R. ALT, D.C., S.C.
Entity type:Organization
Organization Name:DALE R. ALT, D.C., S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:ALT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-887-3717
Mailing Address - Street 1:127 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2107
Mailing Address - Country:US
Mailing Address - Phone:920-887-3717
Mailing Address - Fax:920-887-0220
Practice Address - Street 1:127 PARK AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2107
Practice Address - Country:US
Practice Address - Phone:920-887-3717
Practice Address - Fax:920-887-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2007-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38833700Medicaid
WI38833700Medicaid
WI75-881Medicare ID - Type Unspecified