Provider Demographics
NPI: | 1164940581 |
---|---|
Name: | JOHNSON CHIROPRACTIC CLINIC LLC |
Entity Type: | Organization |
Organization Name: | JOHNSON CHIROPRACTIC CLINIC LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CHIROPRACTOR |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | SYDNEY |
Authorized Official - Middle Name: | M |
Authorized Official - Last Name: | SCHMUS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DC |
Authorized Official - Phone: | 608-742-5578 |
Mailing Address - Street 1: | PO BOX 72 |
Mailing Address - Street 2: | |
Mailing Address - City: | PORTAGE |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 53901-0072 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 608-472-5578 |
Mailing Address - Fax: | 608-742-7028 |
Practice Address - Street 1: | 1512 NEW PINERY RD |
Practice Address - Street 2: | |
Practice Address - City: | PORTAGE |
Practice Address - State: | WI |
Practice Address - Zip Code: | 53901-1312 |
Practice Address - Country: | US |
Practice Address - Phone: | 608-742-5578 |
Practice Address - Fax: | 608-742-7028 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-09-06 |
Last Update Date: | 2017-09-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WI | 4844 | 111N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor | Group - Single Specialty |