Provider Demographics
NPI:1306197009
Name:DYNAMIC CHIROPRACTIC, LTD
Entity Type:Organization
Organization Name:DYNAMIC CHIROPRACTIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:S
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-321-2832
Mailing Address - Street 1:858 HANSEN RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5324
Mailing Address - Country:US
Mailing Address - Phone:920-321-2832
Mailing Address - Fax:920-321-2834
Practice Address - Street 1:858 HANSEN RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5324
Practice Address - Country:US
Practice Address - Phone:920-321-2832
Practice Address - Fax:920-321-2834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4337-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty