Provider Demographics
NPI:1487028205
Name:WOLF RIVER CHIROPRACTIC
Entity Type:Organization
Organization Name:WOLF RIVER CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOLENE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GARVEY PINTAR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-240-4441
Mailing Address - Street 1:N5644 STATE HIGHWAY 76
Mailing Address - Street 2:
Mailing Address - City:SHIOCTON
Mailing Address - State:WI
Mailing Address - Zip Code:54170-8612
Mailing Address - Country:US
Mailing Address - Phone:920-240-4441
Mailing Address - Fax:920-240-4442
Practice Address - Street 1:N5644 STATE HIGHWAY 76
Practice Address - Street 2:
Practice Address - City:SHIOCTON
Practice Address - State:WI
Practice Address - Zip Code:54170-8612
Practice Address - Country:US
Practice Address - Phone:920-240-4441
Practice Address - Fax:920-240-4442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4305-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38976900Medicaid
WI1598983611OtherINDIVIDUAL NPI
WIV12249Medicare UPIN