Provider Demographics
NPI:1073514527
Name:BLACK RIVER CHIROPRACTIC CENTER, SC
Entity Type:Organization
Organization Name:BLACK RIVER CHIROPRACTIC CENTER, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:V
Authorized Official - Last Name:JEAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC DABCO
Authorized Official - Phone:715-284-2915
Mailing Address - Street 1:126 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-1726
Mailing Address - Country:US
Mailing Address - Phone:715-284-2915
Mailing Address - Fax:715-284-7492
Practice Address - Street 1:154 E 5TH ST
Practice Address - Street 2:
Practice Address - City:NEILLSVILLE
Practice Address - State:WI
Practice Address - Zip Code:54456-1941
Practice Address - Country:US
Practice Address - Phone:715-743-3404
Practice Address - Fax:715-743-4449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38996500Medicaid
WI38996500Medicaid