Provider Demographics
NPI:1174654024
Name:GOETZKE CHIROPRACTIC INC.
Entity Type:Organization
Organization Name:GOETZKE CHIROPRACTIC INC.
Other - Org Name:ARCH CHIROPRACITC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:GONSOWSKI
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:715-246-5600
Mailing Address - Street 1:1656 DORSET LN
Mailing Address - Street 2:STE 400
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-2449
Mailing Address - Country:US
Mailing Address - Phone:715-246-5600
Mailing Address - Fax:715-246-5806
Practice Address - Street 1:1656 DORSET LN
Practice Address - Street 2:STE 400
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-2449
Practice Address - Country:US
Practice Address - Phone:715-246-5600
Practice Address - Fax:715-246-5806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3847-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU38636Medicare UPIN
WI000035594Medicare ID - Type Unspecified