Provider Demographics
NPI:1285632901
Name:BOSQUEZ, MICHAEL LAWRENCE (DC, CCEP)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:BOSQUEZ
Suffix:
Gender:M
Credentials:DC, CCEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:OMRO
Mailing Address - State:WI
Mailing Address - Zip Code:54963-9373
Mailing Address - Country:US
Mailing Address - Phone:920-685-3015
Mailing Address - Fax:920-685-3017
Practice Address - Street 1:836 WILLOW ST
Practice Address - Street 2:
Practice Address - City:OMRO
Practice Address - State:WI
Practice Address - Zip Code:54963-9373
Practice Address - Country:US
Practice Address - Phone:920-685-3015
Practice Address - Fax:920-685-3017
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3157111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38885500Medicaid
U54339Medicare UPIN
WI000135713Medicare ID - Type Unspecified