Provider Demographics
NPI:1114335536
Name:THE CENTER FOR COMPREHENSIVE CHIROPRACTIC CARE
Entity Type:Organization
Organization Name:THE CENTER FOR COMPREHENSIVE CHIROPRACTIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIETZE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-848-2392
Mailing Address - Street 1:420 N CHESTNUT AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:OCONTO FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54154-1109
Mailing Address - Country:US
Mailing Address - Phone:920-848-2392
Mailing Address - Fax:
Practice Address - Street 1:420 N CHESTNUT AVE
Practice Address - Street 2:SUITE B
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1109
Practice Address - Country:US
Practice Address - Phone:920-848-2392
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-29
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4951-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty