Provider Demographics
NPI:1568173326
Name:WINNEBAGO WELLNESS LLC
Entity Type:Organization
Organization Name:WINNEBAGO WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:MOOTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-385-9499
Mailing Address - Street 1:9517 LAURA LN
Mailing Address - Street 2:
Mailing Address - City:WINNECONNE
Mailing Address - State:WI
Mailing Address - Zip Code:54986-9627
Mailing Address - Country:US
Mailing Address - Phone:608-547-1379
Mailing Address - Fax:
Practice Address - Street 1:102 N 13TH AVE
Practice Address - Street 2:
Practice Address - City:WINNECONNE
Practice Address - State:WI
Practice Address - Zip Code:54986
Practice Address - Country:US
Practice Address - Phone:920-385-9499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-12
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1164820155Medicaid