Provider Demographics
NPI:1023179942
Name:KLUSENDORF CHIROPRACTIC SC
Entity Type:Organization
Organization Name:KLUSENDORF CHIROPRACTIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR OF CHIROPRACTIC OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KLUSENDORF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-735-0773
Mailing Address - Street 1:2505 E EVERGREEN DR
Mailing Address - Street 2:STE A
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8910
Mailing Address - Country:US
Mailing Address - Phone:920-735-0773
Mailing Address - Fax:920-735-0293
Practice Address - Street 1:2505 E EVERGREEN DR
Practice Address - Street 2:STE
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8910
Practice Address - Country:US
Practice Address - Phone:920-735-0773
Practice Address - Fax:920-735-0293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1690111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT62440Medicare ID - Type UnspecifiedMEDICARE PROVIDER #000035
T62440Medicare UPIN