Provider Demographics
NPI:1306001904
Name:HIETPAS CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:HIETPAS CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CATHLEEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HIETPAS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-743-2200
Mailing Address - Street 1:1444 EGG HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1240
Mailing Address - Country:US
Mailing Address - Phone:920-743-2200
Mailing Address - Fax:920-743-2250
Practice Address - Street 1:1444 EGG HARBOR RD
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1240
Practice Address - Country:US
Practice Address - Phone:920-743-2200
Practice Address - Fax:920-743-2250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2818111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38880000Medicaid
000035636Medicare PIN