Provider Demographics
NPI:1073681409
Name:JUDY F. ELLEFSON, D.C., S.C.
Entity Type:Organization
Organization Name:JUDY F. ELLEFSON, D.C., S.C.
Other - Org Name:FAMILY & SPORTS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:F
Authorized Official - Last Name:ELLEFSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-830-2990
Mailing Address - Street 1:3000 N BALLARD RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8319
Mailing Address - Country:US
Mailing Address - Phone:920-830-2990
Mailing Address - Fax:920-830-0244
Practice Address - Street 1:3000 N BALLARD RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8319
Practice Address - Country:US
Practice Address - Phone:920-830-2990
Practice Address - Fax:920-830-0244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39004400Medicaid
WI39004400Medicaid