Provider Demographics
NPI:1629251160
Name:TENNISWOOD FAMILY CHIROPRACTIC S.C.
Entity Type:Organization
Organization Name:TENNISWOOD FAMILY CHIROPRACTIC S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:TENNISWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-786-3670
Mailing Address - Street 1:PO BOX 852
Mailing Address - Street 2:1537 HERITAGE BLVD
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669-0852
Mailing Address - Country:US
Mailing Address - Phone:608-786-3670
Mailing Address - Fax:608-786-3672
Practice Address - Street 1:1537 HERITAGE BLVD
Practice Address - Street 2:1537 HERITAGE BLVD
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669-9404
Practice Address - Country:US
Practice Address - Phone:608-786-3670
Practice Address - Fax:608-786-3672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000070920Medicare UPIN