Provider Demographics
NPI:1568653665
Name:DIERCKS FAMILY HEALTH CTR., LLC
Entity Type:Organization
Organization Name:DIERCKS FAMILY HEALTH CTR., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:DIERCKS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-623-7812
Mailing Address - Street 1:1111 LANGLADE RD
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-2738
Mailing Address - Country:US
Mailing Address - Phone:715-623-3761
Mailing Address - Fax:715-623-3764
Practice Address - Street 1:1111 LANGLADE RD
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2738
Practice Address - Country:US
Practice Address - Phone:715-623-3761
Practice Address - Fax:715-623-3764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4179-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty