Provider Demographics
NPI:1093458192
Name:NICK LUNDBOHM LLC
Entity Type:Organization
Organization Name:NICK LUNDBOHM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:LUNDBOHM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:877-442-4476
Mailing Address - Street 1:N174W20044 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WI
Mailing Address - Zip Code:53037-9108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N56W15560 SILVER SPRING DR.
Practice Address - Street 2:SUITE E EAST
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-6148
Practice Address - Country:US
Practice Address - Phone:877-442-4476
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-16
Last Update Date:2022-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty