Provider Demographics
NPI:1497290761
Name:ADVANCED SPINE CENTER, S.C.
Entity Type:Organization
Organization Name:ADVANCED SPINE CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUSMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-512-1661
Mailing Address - Street 1:11203 N BUNTROCK AVE
Mailing Address - Street 2:100
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1857
Mailing Address - Country:US
Mailing Address - Phone:262-512-1661
Mailing Address - Fax:262-512-1663
Practice Address - Street 1:11203 N BUNTROCK AVE
Practice Address - Street 2:100
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-1857
Practice Address - Country:US
Practice Address - Phone:262-512-1661
Practice Address - Fax:262-512-1663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4239-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty