Provider Demographics
NPI:1225148133
Name:TRI COUNTY CHIROPRACTIC SC
Entity Type:Organization
Organization Name:TRI COUNTY CHIROPRACTIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CHRIOPRACTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROEBKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-730-1155
Mailing Address - Street 1:702 EISENHOWER DRIVE SUITE G
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:WI
Mailing Address - Zip Code:54136
Mailing Address - Country:US
Mailing Address - Phone:920-730-1155
Mailing Address - Fax:920-730-1148
Practice Address - Street 1:702 EISENHOWER DRIVE SUITE G
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:WI
Practice Address - Zip Code:54136
Practice Address - Country:US
Practice Address - Phone:920-730-1155
Practice Address - Fax:920-730-1148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38995300Medicaid
WI000070535Medicare ID - Type Unspecified