Provider Demographics
NPI:1043263411
Name:DODGE COUNTY CHIROPRACTIC SERVICE CORPORATION
Entity Type:Organization
Organization Name:DODGE COUNTY CHIROPRACTIC SERVICE CORPORATION
Other - Org Name:CHIROPRACTIC USA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENIFER
Authorized Official - Middle Name:E
Authorized Official - Last Name:ESPENSCHEID
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-885-0641
Mailing Address - Street 1:105 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3012
Mailing Address - Country:US
Mailing Address - Phone:920-885-0641
Mailing Address - Fax:920-885-0643
Practice Address - Street 1:105 WARREN ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3012
Practice Address - Country:US
Practice Address - Phone:920-885-0641
Practice Address - Fax:920-885-0643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU60484Medicare UPIN