Provider Demographics
NPI:1205203197
Name:CARLSON CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:CARLSON CHIROPRACTIC CLINIC LLC
Other - Org Name:PHILIP CARLSON, D.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-223-1511
Mailing Address - Street 1:P.O. 26
Mailing Address - Street 2:111 S. FIRST STREET
Mailing Address - City:COLBY
Mailing Address - State:WI
Mailing Address - Zip Code:54421-0026
Mailing Address - Country:US
Mailing Address - Phone:715-223-1511
Mailing Address - Fax:715-223-1411
Practice Address - Street 1:111 S. FIRST STREET
Practice Address - Street 2:
Practice Address - City:COLBY
Practice Address - State:WI
Practice Address - Zip Code:54421-0026
Practice Address - Country:US
Practice Address - Phone:715-223-1511
Practice Address - Fax:715-223-1411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3466-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38904300Medicaid
WIV69848Medicare UPIN
WI38904300Medicaid