Provider Demographics
NPI:1477533818
Name:SUPER, REBECCA J (DC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:SUPER
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 1:410 DALY AVE
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-4744
Mailing Address - Country:US
Mailing Address - Phone:715-423-5050
Mailing Address - Fax:715-423-5086
Practice Address - Street 1:410 DALY AVE
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-4744
Practice Address - Country:US
Practice Address - Phone:715-423-5050
Practice Address - Fax:715-423-5086
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2899012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38875000Medicaid
WI38875000Medicaid