Provider Demographics
NPI:1346658903
Name:WINNECONNE CHIROPRACTIC AND SPORTS REHAB LLC
Entity Type:Organization
Organization Name:WINNECONNE CHIROPRACTIC AND SPORTS REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:KELLOGG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-915-4210
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:WINNECONNE
Mailing Address - State:WI
Mailing Address - Zip Code:54986-0365
Mailing Address - Country:US
Mailing Address - Phone:920-706-0178
Mailing Address - Fax:920-706-0179
Practice Address - Street 1:238 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:WINNECONNE
Practice Address - State:WI
Practice Address - Zip Code:54986
Practice Address - Country:US
Practice Address - Phone:920-706-0178
Practice Address - Fax:920-706-0179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4667-012111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1619278819Medicaid
WI357740001Medicare UPIN