Provider Demographics
NPI:1508910514
Name:REIDT, JIMMY A (DC)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:A
Last Name:REIDT
Suffix:
Gender:M
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:PO BOX 637
Mailing Address - Street 2:
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871-0637
Mailing Address - Country:US
Mailing Address - Phone:715-468-2275
Mailing Address - Fax:
Practice Address - Street 1:17 5TH AVE
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871
Practice Address - Country:US
Practice Address - Phone:715-468-2275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2861111N00000X
MN3069111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38867700Medicaid
WI000270330Medicare PIN
WI38867700Medicaid