Provider Demographics
NPI:1285781203
Name:STREBLOW CHIROPRACTIC OFFICE LLC
Entity type:Organization
Organization Name:STREBLOW CHIROPRACTIC OFFICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:STREBLOW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-775-9666
Mailing Address - Street 1:PO BOX 55
Mailing Address - Street 2:715 CHRISTEL DR
Mailing Address - City:VALDERS
Mailing Address - State:WI
Mailing Address - Zip Code:54245-0055
Mailing Address - Country:US
Mailing Address - Phone:920-775-9666
Mailing Address - Fax:920-775-9791
Practice Address - Street 1:715 CHRISTEL DR
Practice Address - Street 2:
Practice Address - City:VALDERS
Practice Address - State:WI
Practice Address - Zip Code:54245-0055
Practice Address - Country:US
Practice Address - Phone:920-775-9666
Practice Address - Fax:920-775-9791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3440-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38944800Medicaid
WIU65827Medicare UPIN
WI000035752-0001Medicare ID - Type Unspecified