Provider Demographics
NPI:1386110773
Name:CUNNINGHAM, MACKENZIE MARIE (DC)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:MARIE
Last Name:CUNNINGHAM
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 1:188 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:WI
Mailing Address - Zip Code:53803-9711
Mailing Address - Country:US
Mailing Address - Phone:608-759-6152
Mailing Address - Fax:
Practice Address - Street 1:188 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:WI
Practice Address - Zip Code:53803-9711
Practice Address - Country:US
Practice Address - Phone:608-759-6152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5398-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor