Provider Demographics
NPI:1407919525
Name:CLOVER CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:CLOVER CHIROPRACTIC LLC
Other - Org Name:WISCONSIN SPINAL CORRECTION CENTER LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:CLOVER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-722-7947
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54957-0246
Mailing Address - Country:US
Mailing Address - Phone:920-722-7947
Mailing Address - Fax:920-722-7949
Practice Address - Street 1:1576 LYON DR
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-5069
Practice Address - Country:US
Practice Address - Phone:920-722-7947
Practice Address - Fax:920-722-7949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4089-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38966100Medicaid
WI000035771Medicare ID - Type Unspecified
WI38966100Medicaid
WI000035771Medicare PIN