Provider Demographics
NPI:1316095185
Name:COUNTRYVIEW CHIROPRACTIC CLINIC, S.C.
Entity type:Organization
Organization Name:COUNTRYVIEW CHIROPRACTIC CLINIC, S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:PENSIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-526-6158
Mailing Address - Street 1:PO BOX 60
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-0060
Mailing Address - Country:US
Mailing Address - Phone:715-526-6158
Mailing Address - Fax:715-526-6178
Practice Address - Street 1:W5675 CTY HWY B
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-0060
Practice Address - Country:US
Practice Address - Phone:715-526-6158
Practice Address - Fax:715-526-6178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38982000Medicaid
WI38982000Medicaid
WI38982000Medicaid