Provider Demographics
NPI:1346653623
Name:VAN ROO CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:VAN ROO CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:B
Authorized Official - Last Name:VAN ROO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-926-6001
Mailing Address - Street 1:910 COUNTRYSIDE PKWY
Mailing Address - Street 2:
Mailing Address - City:MONDOVI
Mailing Address - State:WI
Mailing Address - Zip Code:54755-6000
Mailing Address - Country:US
Mailing Address - Phone:715-926-6001
Mailing Address - Fax:715-926-6002
Practice Address - Street 1:910 COUNTRYSIDE PKWY
Practice Address - Street 2:
Practice Address - City:MONDOVI
Practice Address - State:WI
Practice Address - Zip Code:54755-6000
Practice Address - Country:US
Practice Address - Phone:715-926-6001
Practice Address - Fax:715-926-6002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3432111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38901000Medicaid
WI38901000Medicaid