Provider Demographics
NPI:1376644567
Name:BREIDENBACH, AMY KAY (DC DICCP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:KAY
Last Name:BREIDENBACH
Suffix:
Gender:F
Credentials:DC DICCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N5498 ST RD 35
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650
Mailing Address - Country:US
Mailing Address - Phone:608-779-5323
Mailing Address - Fax:608-779-5328
Practice Address - Street 1:N5498 ST RD 35
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650
Practice Address - Country:US
Practice Address - Phone:608-779-5323
Practice Address - Fax:608-779-5328
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3732012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38930000Medicaid
U83038Medicare UPIN