Provider Demographics
NPI:1366009532
Name:920 WELLNESS STUDIO LLC
Entity Type:Organization
Organization Name:920 WELLNESS STUDIO LLC
Other - Org Name:920 WELLNESS STUDIO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:MIKHAILA
Authorized Official - Middle Name:
Authorized Official - Last Name:RISKA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-850-6093
Mailing Address - Street 1:3232 N BALLARD RD STE 202
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8804
Mailing Address - Country:US
Mailing Address - Phone:920-850-6093
Mailing Address - Fax:
Practice Address - Street 1:3232 N BALLARD RD STE 202
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8804
Practice Address - Country:US
Practice Address - Phone:920-850-6093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-23
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1134782873Medicaid