Provider Demographics
NPI:1083735583
Name:FAMILY CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:FAMILY CHIROPRACTIC CLINIC INC
Other - Org Name:MADISON CHIROPRACTIC NORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNABB
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-244-0044
Mailing Address - Street 1:2205 N SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-3310
Mailing Address - Country:US
Mailing Address - Phone:608-244-0044
Mailing Address - Fax:
Practice Address - Street 1:2205 N SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-3310
Practice Address - Country:US
Practice Address - Phone:608-244-0044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1579111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1346212099OtherDANIEL SODERHOLM NPI
WI38777500Medicaid
WI1083686737OtherROSS ROYSTER NPI
WI1356313001OtherBRENT MCNABB NPI
WI1692OtherDANIEL SODERHOLM LICENSE
WI38767300Medicaid
WI1579OtherBRENT MCNABB LICENSE
WI38767400Medicaid
WI1619OtherROSS ROYSTER LICENSE
WI1356313001OtherBRENT MCNABB NPI
WI1356313001OtherBRENT MCNABB NPI
WI000290217Medicare ID - Type UnspecifiedROSS ROYSTER
WI=========014OtherBLUE CROSS BLUE SHIELD
WIT63372Medicare UPIN
WIT62730Medicare UPIN
WI000190217Medicare ID - Type UnspecifiedBRENT MCNABB
WI38777500Medicaid