Provider Demographics
NPI:1306915079
Name:BAKKE CHIROPRACTIC CLINIC SC
Entity type:Organization
Organization Name:BAKKE CHIROPRACTIC CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:BAKKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-846-3333
Mailing Address - Street 1:BAKKE CHIROPRACTIC CLINIC SC
Mailing Address - Street 2:312 EAST NORTH STREET
Mailing Address - City:DEFOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532
Mailing Address - Country:US
Mailing Address - Phone:608-846-3337
Mailing Address - Fax:608-846-7033
Practice Address - Street 1:BAKKE CHIROPRACTIC CLINIC SC
Practice Address - Street 2:312 EAST NORTH STREET
Practice Address - City:DEFOREST
Practice Address - State:WI
Practice Address - Zip Code:53532
Practice Address - Country:US
Practice Address - Phone:608-846-3337
Practice Address - Fax:608-846-7033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35710Medicare PIN