Provider Demographics
NPI:1447758354
Name:OSHKOSH SPINE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:OSHKOSH SPINE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:DONALD JOSEPH
Authorized Official - Last Name:AUGUSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-277-8940
Mailing Address - Street 1:PO BOX 62
Mailing Address - Street 2:
Mailing Address - City:MANAWA
Mailing Address - State:WI
Mailing Address - Zip Code:54949-0062
Mailing Address - Country:US
Mailing Address - Phone:920-277-8940
Mailing Address - Fax:
Practice Address - Street 1:1210 S KOELLER ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-6170
Practice Address - Country:US
Practice Address - Phone:920-235-0000
Practice Address - Fax:920-235-3522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5293-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty