Provider Demographics
NPI:1619087871
Name:LAKE DELTON CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:LAKE DELTON CHIROPRACTIC CLINIC LLC
Other - Org Name:HEALTHSOURCE CHIROPRACTIC & PROGRESSIVE WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-697-9994
Mailing Address - Street 1:151 WISCONSIN DELLS PKWY S
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN DELLS
Mailing Address - State:WI
Mailing Address - Zip Code:53965
Mailing Address - Country:US
Mailing Address - Phone:608-253-0102
Mailing Address - Fax:608-253-0188
Practice Address - Street 1:151 WISCONSIN DELLS PKWY S
Practice Address - Street 2:
Practice Address - City:WISCONSIN DELLS
Practice Address - State:WI
Practice Address - Zip Code:53965
Practice Address - Country:US
Practice Address - Phone:608-253-0102
Practice Address - Fax:608-253-0188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4029-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39000300Medicaid