Provider Demographics
NPI:1528382363
Name:GENESIS FAMILY CHIROPRACTIC SC
Entity Type:Organization
Organization Name:GENESIS FAMILY CHIROPRACTIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:A
Authorized Official - Last Name:LANG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-731-3255
Mailing Address - Street 1:4070 W SPENCER ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-4015
Mailing Address - Country:US
Mailing Address - Phone:920-731-3255
Mailing Address - Fax:920-731-3357
Practice Address - Street 1:1730 APPLETON RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1108
Practice Address - Country:US
Practice Address - Phone:920-886-1055
Practice Address - Fax:920-886-1053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty