Provider Demographics
NPI:1003813817
Name:CLINTON CHIROPRACTIC CLINIC SC
Entity Type:Organization
Organization Name:CLINTON CHIROPRACTIC CLINIC SC
Other - Org Name:CLINTON CHIROPRACTIC CLINIC SC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:DITTMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-676-2210
Mailing Address - Street 1:400 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:WI
Mailing Address - Zip Code:53525-9005
Mailing Address - Country:US
Mailing Address - Phone:608-676-2210
Mailing Address - Fax:608-676-5947
Practice Address - Street 1:400 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:WI
Practice Address - Zip Code:53525-9005
Practice Address - Country:US
Practice Address - Phone:608-676-2210
Practice Address - Fax:608-676-5947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3029012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI00035809Medicare PIN
U48813Medicare UPIN