Provider Demographics
NPI:1225313422
Name:GUNDLACH CHIROPRACTIC, SC
Entity Type:Organization
Organization Name:GUNDLACH CHIROPRACTIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:OSCAR
Authorized Official - Last Name:GUNDLACH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-745-3020
Mailing Address - Street 1:315 MOUNT ZION DR
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:WI
Mailing Address - Zip Code:54971-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 MOUNT ZION DR
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-1713
Practice Address - Country:US
Practice Address - Phone:920-745-3020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2307-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38842600Medicaid
WI75952Medicare PIN
WIT62082Medicare UPIN