Provider Demographics
NPI:1326262916
Name:RACINE CHIROPRACTIC LTD
Entity Type:Organization
Organization Name:RACINE CHIROPRACTIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILSON
Authorized Official - Middle Name:
Authorized Official - Last Name:MBURU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-639-9514
Mailing Address - Street 1:3845 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-3228
Mailing Address - Country:US
Mailing Address - Phone:262-639-9514
Mailing Address - Fax:262-639-9529
Practice Address - Street 1:3845 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-3228
Practice Address - Country:US
Practice Address - Phone:262-639-9514
Practice Address - Fax:262-639-9529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2314-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========013OtherBLUE CROSS AND BLUE SHIEL