Provider Demographics
NPI:1508998188
Name:ELITE CHIROPRACTIC SHEBOYGAN SC
Entity Type:Organization
Organization Name:ELITE CHIROPRACTIC SHEBOYGAN SC
Other - Org Name:WISCONSIN SPINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-910-6600
Mailing Address - Street 1:20456 LAKE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-7805
Mailing Address - Country:US
Mailing Address - Phone:612-910-6600
Mailing Address - Fax:952-492-5913
Practice Address - Street 1:1720 N 8TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-2773
Practice Address - Country:US
Practice Address - Phone:920-803-2225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty