Provider Demographics
NPI:1043685316
Name:GROTH CHIROPRACTIC CLINC INC
Entity Type:Organization
Organization Name:GROTH CHIROPRACTIC CLINC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:GROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-786-3670
Mailing Address - Street 1:1540 HERITAGE BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669-1417
Mailing Address - Country:US
Mailing Address - Phone:608-786-3670
Mailing Address - Fax:608-786-3672
Practice Address - Street 1:1540 HERITAGE BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669-1417
Practice Address - Country:US
Practice Address - Phone:608-786-3670
Practice Address - Fax:608-786-3672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI410912111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty