Provider Demographics
NPI:1467503656
Name:KETTLE MORAINE HEALTH & WELLNESS LLC
Entity Type:Organization
Organization Name:KETTLE MORAINE HEALTH & WELLNESS LLC
Other - Org Name:UNITED CHIROPRACTIC SPORTS & REHA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR AND OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR OF CHIROPRACT
Authorized Official - Phone:262-723-3235
Mailing Address - Street 1:422 N WISCONSIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-1318
Mailing Address - Country:US
Mailing Address - Phone:262-723-3235
Mailing Address - Fax:262-723-8621
Practice Address - Street 1:422 N WISCONSIN ST STE A
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-1318
Practice Address - Country:US
Practice Address - Phone:262-723-3235
Practice Address - Fax:262-723-8621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3859-012111N00000X
MN4229111N00000X
IL38010724111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39004100Medicaid
WI390747208005OtherBCBS DR. TODDS PIN
WI776235397018OtherBCBS CLINIC
WI38943900Medicaid
WI000135821Medicare PIN
WIU94587Medicare UPIN
WI390747208005OtherBCBS DR. TODDS PIN