Provider Demographics
NPI:1467667972
Name:CHIROPRACTIC HEALTH & REHABILITATION CENTER
Entity Type:Organization
Organization Name:CHIROPRACTIC HEALTH & REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:DORN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-757-5771
Mailing Address - Street 1:N1724 MUNICIPAL DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54942-8721
Mailing Address - Country:US
Mailing Address - Phone:920-757-5771
Mailing Address - Fax:920-757-0373
Practice Address - Street 1:N1724 MUNICIPAL DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:WI
Practice Address - Zip Code:54942-8721
Practice Address - Country:US
Practice Address - Phone:920-757-5771
Practice Address - Fax:920-757-0373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4025 012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38956200Medicaid
000035641Medicare PIN