Provider Demographics
NPI:1124194790
Name:WAUPACA CHIROPRACTIC CENTER, INC
Entity Type:Organization
Organization Name:WAUPACA CHIROPRACTIC CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:LEEAN-RODENZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-258-8211
Mailing Address - Street 1:304 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-5703
Mailing Address - Country:US
Mailing Address - Phone:715-258-8211
Mailing Address - Fax:
Practice Address - Street 1:304 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-5703
Practice Address - Country:US
Practice Address - Phone:715-258-8211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3651111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38934000Medicaid