Provider Demographics
NPI:1174682553
Name:KETTLE MORAINE CHIROPRACTIC CLINIC SC
Entity Type:Organization
Organization Name:KETTLE MORAINE CHIROPRACTIC CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:GRONSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-334-1011
Mailing Address - Street 1:223 W PARADISE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-4903
Mailing Address - Country:US
Mailing Address - Phone:262-334-1011
Mailing Address - Fax:262-338-0306
Practice Address - Street 1:223 W PARADISE DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-4903
Practice Address - Country:US
Practice Address - Phone:262-334-1011
Practice Address - Fax:262-338-0306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2539012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38863700Medicaid
WI38863700Medicaid
WI70394Medicare ID - Type Unspecified