Provider Demographics
NPI:1164010104
Name:GREEN BAY CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:GREEN BAY CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-490-0200
Mailing Address - Street 1:515 S MILITARY AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2209
Mailing Address - Country:US
Mailing Address - Phone:920-490-0200
Mailing Address - Fax:920-490-9698
Practice Address - Street 1:515 S MILITARY AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2209
Practice Address - Country:US
Practice Address - Phone:920-490-0200
Practice Address - Fax:920-490-9698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty