Provider Demographics
NPI:1629546726
Name:OGI CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:OGI CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:OGI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-477-1040
Mailing Address - Street 1:1040 FOND DU LAC AVE
Mailing Address - Street 2:
Mailing Address - City:KEWASKUM
Mailing Address - State:WI
Mailing Address - Zip Code:53040-9590
Mailing Address - Country:US
Mailing Address - Phone:262-477-1040
Mailing Address - Fax:262-247-0645
Practice Address - Street 1:1040 FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:KEWASKUM
Practice Address - State:WI
Practice Address - Zip Code:53040-9590
Practice Address - Country:US
Practice Address - Phone:262-477-1040
Practice Address - Fax:262-247-0645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100020814Medicaid