Provider Demographics
NPI:1407946254
Name:LAKE GENEVA CHIROPRACTIC PARTNERS
Entity Type:Organization
Organization Name:LAKE GENEVA CHIROPRACTIC PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:BUNTROCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-248-8177
Mailing Address - Street 1:612 S WELLS ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2159
Mailing Address - Country:US
Mailing Address - Phone:262-248-8177
Mailing Address - Fax:262-248-6393
Practice Address - Street 1:612 S WELLS ST
Practice Address - Street 2:SUITE C
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2159
Practice Address - Country:US
Practice Address - Phone:262-248-8177
Practice Address - Fax:262-248-6393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2834-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38863200Medicaid
WI38863200Medicaid