Provider Demographics
NPI:1568786051
Name:LODI CHIROPRACTIC CLINIC, LLC
Entity Type:Organization
Organization Name:LODI CHIROPRACTIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-592-7030
Mailing Address - Street 1:154 LODI ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:WI
Mailing Address - Zip Code:53555-1217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:154 LODI ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:WI
Practice Address - Zip Code:53555-1217
Practice Address - Country:US
Practice Address - Phone:608-592-7030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-26
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3161-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0000035196Medicare NSC