Provider Demographics
NPI:1629063458
Name:DR THOMAS J SOLECKI JR SC
Entity Type:Organization
Organization Name:DR THOMAS J SOLECKI JR SC
Other - Org Name:SPORTS & FAMILY CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:COUNTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-925-9000
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53141-0158
Mailing Address - Country:US
Mailing Address - Phone:262-925-9000
Mailing Address - Fax:262-925-8997
Practice Address - Street 1:6123 GREEN BAY RD
Practice Address - Street 2:SUITE 140
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2927
Practice Address - Country:US
Practice Address - Phone:262-653-9208
Practice Address - Fax:262-653-9264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3590111N00000X
IL038009230111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38910800Medicaid
398964451007OtherBCBS OF WI
U74341Medicare UPIN
WI38910800Medicaid