Provider Demographics
NPI:1083772735
Name:KETTLE MORAINE HEALTH CENTER, S.C.
Entity Type:Organization
Organization Name:KETTLE MORAINE HEALTH CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:VENSKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-646-2123
Mailing Address - Street 1:2725 HILLSIDE DR STE A
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-2165
Mailing Address - Country:US
Mailing Address - Phone:262-646-2123
Mailing Address - Fax:262-646-5615
Practice Address - Street 1:2725 HILLSIDE DR STE A
Practice Address - Street 2:
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-2165
Practice Address - Country:US
Practice Address - Phone:262-646-2123
Practice Address - Fax:262-646-5615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2023-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3384111N00000X
WI33436174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty