Provider Demographics
NPI:1407053911
Name:MAYVILLE CHIROPRACTIC CENTER LLC
Entity Type:Organization
Organization Name:MAYVILLE CHIROPRACTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:RIEGLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-387-5995
Mailing Address - Street 1:1 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53050-1641
Mailing Address - Country:US
Mailing Address - Phone:920-387-5995
Mailing Address - Fax:920-387-5887
Practice Address - Street 1:1 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:WI
Practice Address - Zip Code:53050-1641
Practice Address - Country:US
Practice Address - Phone:920-387-5995
Practice Address - Fax:920-387-5887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2075-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT63101Medicare UPIN
WI000035753Medicare ID - Type Unspecified