Provider Demographics
NPI:1629078902
Name:HOLLIDAY, CHANELLE R (DC)
Entity Type:Individual
Prefix:DR
First Name:CHANELLE
Middle Name:R
Last Name:HOLLIDAY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-1726
Mailing Address - Country:US
Mailing Address - Phone:715-284-2915
Mailing Address - Fax:715-284-7492
Practice Address - Street 1:126 S 2ND ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-1726
Practice Address - Country:US
Practice Address - Phone:715-284-2915
Practice Address - Fax:715-284-7492
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3715111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI205747937017OtherBCBS
WI38929100Medicaid
U82941Medicare UPIN