Provider Demographics
NPI:1720120868
Name:HEFFERNAN CHIROPRACTIC CLINIC SC
Entity type:Organization
Organization Name:HEFFERNAN CHIROPRACTIC CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:HEFFERNAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-549-4555
Mailing Address - Street 1:1820 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-3902
Mailing Address - Country:US
Mailing Address - Phone:262-549-4555
Mailing Address - Fax:262-549-9750
Practice Address - Street 1:1820 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-3902
Practice Address - Country:US
Practice Address - Phone:262-549-4555
Practice Address - Fax:262-549-9750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1326-012111N00000X
WI3874-012111N00000X
WI3558-012111N00000X
WI2077-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38181900Medicaid
WI38828400Medicaid
WIT62165Medicare UPIN
WI38181900Medicaid