Provider Demographics
NPI:1235500638
Name:ANTIGO CHIROPRACTIC HEALTH CENTER, INC
Entity Type:Organization
Organization Name:ANTIGO CHIROPRACTIC HEALTH CENTER, INC
Other - Org Name:GOLDSWORTHY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSWORTHY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-623-7141
Mailing Address - Street 1:941 CENTURY AVE
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-2484
Mailing Address - Country:US
Mailing Address - Phone:715-623-7141
Mailing Address - Fax:
Practice Address - Street 1:941 CENTURY AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2484
Practice Address - Country:US
Practice Address - Phone:715-623-7141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1660-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty