Provider Demographics
NPI:1629000120
Name:NOBLES CHIROPRACTIC WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:NOBLES CHIROPRACTIC WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:W
Authorized Official - Last Name:NOBLES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-276-3401
Mailing Address - Street 1:15481 COMMERCIAL RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54138-9677
Mailing Address - Country:US
Mailing Address - Phone:715-276-3401
Mailing Address - Fax:715-276-1533
Practice Address - Street 1:15481 COMMERCIAL RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WI
Practice Address - Zip Code:54138-9677
Practice Address - Country:US
Practice Address - Phone:715-276-3401
Practice Address - Fax:715-276-1533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3964-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39002300Medicaid
WI39002300Medicaid
WI000075442Medicare PIN
WIU97719Medicare UPIN