Provider Demographics
NPI:1033281167
Name:WIESZTORT FAMILY CHIROPRACTIC CLINIC, S.C.
Entity Type:Organization
Organization Name:WIESZTORT FAMILY CHIROPRACTIC CLINIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:RUDOLPH
Authorized Official - Last Name:WIESZTORT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-694-3530
Mailing Address - Street 1:4014 77TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4314
Mailing Address - Country:US
Mailing Address - Phone:262-694-3530
Mailing Address - Fax:262-925-8810
Practice Address - Street 1:4014 77TH ST STE 2
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4314
Practice Address - Country:US
Practice Address - Phone:262-694-3530
Practice Address - Fax:262-925-8810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3514111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38911900Medicaid
WI000035423Medicare PIN
WI38911900Medicaid
WI4492770001Medicare NSC