Provider Demographics
NPI:1003003716
Name:BLAU CHIROPRACTIC SC
Entity Type:Organization
Organization Name:BLAU CHIROPRACTIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLAU
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-742-1300
Mailing Address - Street 1:641 LATTON LN
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-1078
Mailing Address - Country:US
Mailing Address - Phone:608-742-1300
Mailing Address - Fax:608-745-0147
Practice Address - Street 1:641 LATTON LN
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-1078
Practice Address - Country:US
Practice Address - Phone:608-742-1300
Practice Address - Fax:608-745-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2990111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38887700Medicaid
WI000075332Medicare PIN