Provider Demographics
NPI:1285915397
Name:MADDEROM, MICHELLE M (DC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:MADDEROM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 US HIGHWAY 45 S
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54521-9110
Mailing Address - Country:US
Mailing Address - Phone:715-479-8700
Mailing Address - Fax:
Practice Address - Street 1:761 US HIGHWAY 45 S
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:WI
Practice Address - Zip Code:54521-9110
Practice Address - Country:US
Practice Address - Phone:715-479-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4753-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor