Provider Demographics
NPI:1225186547
Name:NELSON-SIVRET CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:NELSON-SIVRET CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:SIVRET
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-388-4499
Mailing Address - Street 1:402 ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216-1329
Mailing Address - Country:US
Mailing Address - Phone:920-388-4499
Mailing Address - Fax:920-388-4499
Practice Address - Street 1:402 ELLIS ST
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-1329
Practice Address - Country:US
Practice Address - Phone:920-388-4499
Practice Address - Fax:920-388-4499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI111N00000X
WI1781 -012 WI111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38736500Medicaid
WI38736500Medicaid