Provider Demographics
NPI:1144385873
Name:CHIROPLUS COMPLIMENTARY HEALTH CARE CENTER LLC
Entity Type:Organization
Organization Name:CHIROPLUS COMPLIMENTARY HEALTH CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:POMPLUN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-294-3130
Mailing Address - Street 1:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941-0458
Mailing Address - Country:US
Mailing Address - Phone:920-294-3130
Mailing Address - Fax:920-294-3238
Practice Address - Street 1:505 LAKE STREET
Practice Address - Street 2:
Practice Address - City:GREEN LAKE
Practice Address - State:WI
Practice Address - Zip Code:54941
Practice Address - Country:US
Practice Address - Phone:920-294-3130
Practice Address - Fax:920-294-3238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3020111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38873800Medicaid
WI38873800Medicaid
WIU43708Medicare UPIN