Provider Demographics
NPI:1467676338
Name:WAUPUN CHIROPRACTIC CENTER, S.C.
Entity Type:Organization
Organization Name:WAUPUN CHIROPRACTIC CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLOHOWIAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-324-9899
Mailing Address - Street 1:160 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-2276
Mailing Address - Country:US
Mailing Address - Phone:920-324-9899
Mailing Address - Fax:920-324-9898
Practice Address - Street 1:160 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-2276
Practice Address - Country:US
Practice Address - Phone:920-324-9899
Practice Address - Fax:920-324-9898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2757-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38861600Medicaid
WI38955100Medicaid
WI39003000Medicare ID - Type UnspecifiedJAMES BENZSCHAWEL DC
WI38861600Medicaid
WI38955100Medicaid