Provider Demographics
NPI:1396812905
Name:SHERWOOD CHIROPRACTIC SC
Entity type:Organization
Organization Name:SHERWOOD CHIROPRACTIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-989-1599
Mailing Address - Street 1:N275 MILITARY RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SHERWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54169-9603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N275 MILITARY RD
Practice Address - Street 2:SUITE 2
Practice Address - City:SHERWOOD
Practice Address - State:WI
Practice Address - Zip Code:54169-9603
Practice Address - Country:US
Practice Address - Phone:920-989-1599
Practice Address - Fax:920-989-1593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3809-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38937000Medicaid
WIU88756Medicare UPIN