Provider Demographics
NPI:1013197904
Name:RIVER SHORES CHIROPRACTIC SC
Entity Type:Organization
Organization Name:RIVER SHORES CHIROPRACTIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KRYSTI
Authorized Official - Middle Name:K
Authorized Official - Last Name:WICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-573-4465
Mailing Address - Street 1:705 VILLAGE GREEN WAY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53090-2527
Mailing Address - Country:US
Mailing Address - Phone:262-334-4070
Mailing Address - Fax:262-334-4078
Practice Address - Street 1:705 VILLAGE GREEN WAY
Practice Address - Street 2:SUITE 105
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53090-2527
Practice Address - Country:US
Practice Address - Phone:262-334-4070
Practice Address - Fax:262-334-4078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4353-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty