Provider Demographics
NPI:1154321214
Name:SIVRET, CHARLES L (DC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:SIVRET
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216-1329
Mailing Address - Country:US
Mailing Address - Phone:920-388-4499
Mailing Address - Fax:920-388-4499
Practice Address - Street 1:402 ELLIS ST
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-1329
Practice Address - Country:US
Practice Address - Phone:920-388-4499
Practice Address - Fax:920-388-4499
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1807-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000235937OtherMEDICARE PTAN
WI38777700Medicaid
WI000235937OtherMEDICARE PTAN