Provider Demographics
NPI:1306987771
Name:CHIPPEWA VALLEY NEUROSCIENCES LLC
Entity type:Organization
Organization Name:CHIPPEWA VALLEY NEUROSCIENCES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:P
Authorized Official - Last Name:KONZEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:715-831-0811
Mailing Address - Street 1:3506 OAKWOOD MALL DR STE A
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-2639
Mailing Address - Country:US
Mailing Address - Phone:715-831-0811
Mailing Address - Fax:715-831-0802
Practice Address - Street 1:950 W CLAIREMONT AVE
Practice Address - Street 2:SUITE B
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6176
Practice Address - Country:US
Practice Address - Phone:715-831-0811
Practice Address - Fax:715-831-0802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI371380212084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30067800Medicaid
WI30067800Medicaid