Provider Demographics
NPI:1588792600
Name:ALIGN CHIROPRACTIC OF PORT, S.C.
Entity type:Organization
Organization Name:ALIGN CHIROPRACTIC OF PORT, S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHAPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-284-0500
Mailing Address - Street 1:1032 S SPRING ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-2455
Mailing Address - Country:US
Mailing Address - Phone:262-284-0500
Mailing Address - Fax:262-284-1944
Practice Address - Street 1:1032 S SPRING ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2455
Practice Address - Country:US
Practice Address - Phone:262-284-0500
Practice Address - Fax:262-284-1944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1323111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38986700Medicaid
WI70140Medicare ID - Type Unspecified