Provider Demographics
NPI:1568641116
Name:DIETRICH CHIROPRACTIC, SC
Entity Type:Organization
Organization Name:DIETRICH CHIROPRACTIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:DIETIRCH
Authorized Official - Suffix:II
Authorized Official - Credentials:DC
Authorized Official - Phone:715-423-4050
Mailing Address - Street 1:1105 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-3349
Mailing Address - Country:US
Mailing Address - Phone:715-423-4050
Mailing Address - Fax:715-424-3108
Practice Address - Street 1:1105 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54495-3349
Practice Address - Country:US
Practice Address - Phone:715-423-4050
Practice Address - Fax:715-424-3108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3621-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty