Provider Demographics
NPI:1659400653
Name:KEDR LLC
Entity Type:Organization
Organization Name:KEDR LLC
Other - Org Name:CHIROPRACTIC CARE CENTER-BROOKFIELD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KINGA
Authorized Official - Middle Name:E
Authorized Official - Last Name:EBNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-781-0084
Mailing Address - Street 1:4080 N BROOKFIELD RD STE A
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-7445
Mailing Address - Country:US
Mailing Address - Phone:262-781-0084
Mailing Address - Fax:262-781-0090
Practice Address - Street 1:4080 N BROOKFIELD RD STE A
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-7445
Practice Address - Country:US
Practice Address - Phone:262-781-0084
Practice Address - Fax:262-781-0090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3547-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38937200Medicaid
WI38937200Medicaid