Provider Demographics
NPI:1578694253
Name:STAUDENMAIER CHIROPRACTIC WELLNESS CENTER, S.C.
Entity Type:Organization
Organization Name:STAUDENMAIER CHIROPRACTIC WELLNESS CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:STAUDENMAIER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-743-7255
Mailing Address - Street 1:30 N 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-3207
Mailing Address - Country:US
Mailing Address - Phone:920-743-7255
Mailing Address - Fax:920-743-7256
Practice Address - Street 1:30 N 18TH AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-3207
Practice Address - Country:US
Practice Address - Phone:920-743-7255
Practice Address - Fax:920-743-7256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3209-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3209-012OtherSTATE LICENSE NUMBER
WIU53655Medicare UPIN
WI000475581Medicare ID - Type UnspecifiedSEQUENCE & PROVIDER #