Provider Demographics
NPI:1972058261
Name:STUCKY CHIROPRACTIC MENOMONIE S.C.
Entity type:Organization
Organization Name:STUCKY CHIROPRACTIC MENOMONIE S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LEW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-231-2233
Mailing Address - Street 1:700 WOLSKE BAY RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-1612
Mailing Address - Country:US
Mailing Address - Phone:715-231-2233
Mailing Address - Fax:715-231-2236
Practice Address - Street 1:700 WOLSKE BAY RD
Practice Address - Street 2:SUITE 150
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-1612
Practice Address - Country:US
Practice Address - Phone:715-231-2233
Practice Address - Fax:715-231-2236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-17
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4638-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1376854851Medicaid