Provider Demographics
NPI:1548478563
Name:OZAUKEE CHIROPRACTIC CLINIC, LTD
Entity type:Organization
Organization Name:OZAUKEE CHIROPRACTIC CLINIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHELSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-242-5577
Mailing Address - Street 1:122 GREEN BAY RD
Mailing Address - Street 2:P.O. BOX 574
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1624
Mailing Address - Country:US
Mailing Address - Phone:262-242-5577
Mailing Address - Fax:
Practice Address - Street 1:122 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:THIENSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53092-1624
Practice Address - Country:US
Practice Address - Phone:262-242-5577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1806-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT63322Medicare UPIN