Provider Demographics
NPI:1053476168
Name:DORN, CLINT RYAN (DC)
Entity Type:Individual
Prefix:DR
First Name:CLINT
Middle Name:RYAN
Last Name:DORN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:CHIROPRACTIC HEALTH
Other - Middle Name:AND
Other - Last Name:REHABILITATION CENTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:W6905 PARKVIEW DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:GREENVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54942-9099
Mailing Address - Country:US
Mailing Address - Phone:920-757-5771
Mailing Address - Fax:920-757-0373
Practice Address - Street 1:W6905 PARKVIEW DR
Practice Address - Street 2:SUITE B
Practice Address - City:GREENVILLE
Practice Address - State:WI
Practice Address - Zip Code:54942-9099
Practice Address - Country:US
Practice Address - Phone:920-757-5771
Practice Address - Fax:920-757-0373
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4025012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38956200Medicaid
WI38956200Medicaid