Provider Demographics
NPI:1487856019
Name:HIGHLAND CHIROPRACTIC SC
Entity Type:Organization
Organization Name:HIGHLAND CHIROPRACTIC SC
Other - Org Name:COMMUNITY CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-673-7600
Mailing Address - Street 1:1501 E SUMNER ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-2608
Mailing Address - Country:US
Mailing Address - Phone:262-673-7600
Mailing Address - Fax:262-673-7692
Practice Address - Street 1:1501 E SUMNER ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-2608
Practice Address - Country:US
Practice Address - Phone:262-673-7600
Practice Address - Fax:262-673-7692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3880-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38961800Medicaid
WI38961800Medicaid