Provider Demographics
NPI:1518007756
Name:HEINEN CHIROPRACTIC, SC
Entity Type:Organization
Organization Name:HEINEN CHIROPRACTIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HEINEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-451-9960
Mailing Address - Street 1:2103 INDIANA AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-4729
Mailing Address - Country:US
Mailing Address - Phone:920-451-9960
Mailing Address - Fax:920-451-9965
Practice Address - Street 1:2103 INDIANA AVE STE 1A
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4729
Practice Address - Country:US
Practice Address - Phone:920-451-9960
Practice Address - Fax:920-451-9965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38927500Medicaid
WI35269Medicare ID - Type Unspecified
WI38927500Medicaid