Provider Demographics
NPI:1508159088
Name:BREATH OF LIFE CHIROPRACTIC WELLNESS CENTER
Entity Type:Organization
Organization Name:BREATH OF LIFE CHIROPRACTIC WELLNESS CENTER
Other - Org Name:BREATH OF LIFE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DORAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CACCP
Authorized Official - Phone:920-419-1457
Mailing Address - Street 1:3701 S JOHANN DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-7066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1703 S ONEIDA ST
Practice Address - Street 2:SUITE C
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1524
Practice Address - Country:US
Practice Address - Phone:920-419-1457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4205-12261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center