Provider Demographics
NPI:1578889242
Name:SPORTS & FAMILY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:SPORTS & FAMILY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HAE YONG
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-653-9208
Mailing Address - Street 1:6123 GREEN BAY ROAD
Mailing Address - Street 2:STE 140
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142
Mailing Address - Country:US
Mailing Address - Phone:262-653-9208
Mailing Address - Fax:
Practice Address - Street 1:6123 GREEN BAY ROAD
Practice Address - Street 2:STE 140
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142
Practice Address - Country:US
Practice Address - Phone:262-653-9208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4600-012111N00000X
WI4598-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty