Provider Demographics
NPI:1619976263
Name:SMYKAL, TIMOTHY LAWRENCE (DC, FACO, CCSP)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:LAWRENCE
Last Name:SMYKAL
Suffix:
Gender:M
Credentials:DC, FACO, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N96W18743 COUNTY LINE RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-7100
Mailing Address - Country:US
Mailing Address - Phone:262-253-6779
Mailing Address - Fax:262-253-6849
Practice Address - Street 1:N96W18743 COUNTY LINE RD
Practice Address - Street 2:SUITE E
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-7100
Practice Address - Country:US
Practice Address - Phone:262-253-6779
Practice Address - Fax:262-253-6849
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-17
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3243111N00000X, 111NS0005X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38888200Medicaid
U43549Medicare UPIN
WI000046510Medicare PIN