Provider Demographics
NPI:1417532540
Name:LICKTEIG, BENJAMIN JOSEPH
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOSEPH
Last Name:LICKTEIG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 ENLOE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-4539
Mailing Address - Country:US
Mailing Address - Phone:715-690-2910
Mailing Address - Fax:
Practice Address - Street 1:2910 ENLOE ST STE 101
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-4539
Practice Address - Country:US
Practice Address - Phone:952-207-2186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6790111N00000X
WI6094111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor