Provider Demographics
NPI:1467727826
Name:BALLWEG, BREANNA ROSE (DC)
Entity Type:Individual
Prefix:DR
First Name:BREANNA
Middle Name:ROSE
Last Name:BALLWEG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S GAMMON RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1371
Mailing Address - Country:US
Mailing Address - Phone:608-630-9040
Mailing Address - Fax:608-630-9060
Practice Address - Street 1:621 S GAMMON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1371
Practice Address - Country:US
Practice Address - Phone:608-630-9040
Practice Address - Fax:608-630-9060
Is Sole Proprietor?:No
Enumeration Date:2012-03-19
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4875-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100022189Medicaid