Provider Demographics
NPI:1003845587
Name:ALT, DALE R (DC)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:R
Last Name:ALT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2107
Mailing Address - Country:US
Mailing Address - Phone:920-887-3717
Mailing Address - Fax:920-887-0220
Practice Address - Street 1:127 PARK AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2107
Practice Address - Country:US
Practice Address - Phone:920-887-3717
Practice Address - Fax:920-887-0220
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2007111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38833700Medicaid
WI75-881Medicare ID - Type Unspecified
WI38833700Medicaid