Provider Demographics
NPI:1306583687
Name:VANGOETHEM, CARLI MARIE (DC)
Entity type:Individual
Prefix:
First Name:CARLI
Middle Name:MARIE
Last Name:VANGOETHEM
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 1:402 ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216-1329
Mailing Address - Country:US
Mailing Address - Phone:920-621-1854
Mailing Address - Fax:
Practice Address - Street 1:402 ELLIS ST
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-1329
Practice Address - Country:US
Practice Address - Phone:920-388-4499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA114461111N00000X
WI5778-12111NN1001X, 111NR0200X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN1001XChiropractic ProvidersChiropractorNutrition
No111NR0200XChiropractic ProvidersChiropractorRadiology