Provider Demographics
NPI:1619036134
Name:DODGEVILLE FAMILY CHIROPRACTIC SC
Entity Type:Organization
Organization Name:DODGEVILLE FAMILY CHIROPRACTIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-935-1773
Mailing Address - Street 1:401 N UNION ST
Mailing Address - Street 2:
Mailing Address - City:DODGEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53533-1347
Mailing Address - Country:US
Mailing Address - Phone:608-935-1773
Mailing Address - Fax:608-935-1774
Practice Address - Street 1:401 N UNION ST
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-1347
Practice Address - Country:US
Practice Address - Phone:608-935-1773
Practice Address - Fax:608-935-1774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3780111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38932800Medicaid
WI35347Medicare ID - Type UnspecifiedMEDICARE