Provider Demographics
NPI:1164831673
Name:CHIROPRACTIC ASSOCIATES OF KENOSHA, S.C.
Entity Type:Organization
Organization Name:CHIROPRACTIC ASSOCIATES OF KENOSHA, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:TRABBOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-942-9955
Mailing Address - Street 1:3120 80TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4946
Mailing Address - Country:US
Mailing Address - Phone:262-942-9955
Mailing Address - Fax:262-942-9958
Practice Address - Street 1:3120 80TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4946
Practice Address - Country:US
Practice Address - Phone:262-942-9955
Practice Address - Fax:262-942-9958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3665111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38928300Medicaid
WI000035282Medicare PIN
WIU79573Medicare UPIN