Provider Demographics
NPI:1093218745
Name:TUNDRA CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:TUNDRA CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:KALLIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-336-3353
Mailing Address - Street 1:2150 S COURTLAND DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-9360
Mailing Address - Country:US
Mailing Address - Phone:920-336-3353
Mailing Address - Fax:
Practice Address - Street 1:1251 SCHEURING RD
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-1003
Practice Address - Country:US
Practice Address - Phone:920-336-3353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5115-12111N00000X
WI5112-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty