Provider Demographics
NPI:1164454922
Name:ADVANCED FAMILY CHIROPRACTIC, S.C.
Entity Type:Organization
Organization Name:ADVANCED FAMILY CHIROPRACTIC, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FYNAARDT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:414-425-9776
Mailing Address - Street 1:S63W13620 JANESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-2713
Mailing Address - Country:US
Mailing Address - Phone:414-425-9776
Mailing Address - Fax:414-425-9794
Practice Address - Street 1:S63W13620 JANESVILLE RD
Practice Address - Street 2:
Practice Address - City:MUSKEGO
Practice Address - State:WI
Practice Address - Zip Code:53150-2713
Practice Address - Country:US
Practice Address - Phone:414-425-9776
Practice Address - Fax:414-425-9794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2492-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT91944Medicare UPIN