Provider Demographics
NPI:1659551547
Name:IDEAL CHIROPRACTIC
Entity Type:Organization
Organization Name:IDEAL CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-994-2000
Mailing Address - Street 1:PO BOX 196
Mailing Address - Street 2:321 CARROLL STREET
Mailing Address - City:RANDOM LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53075-1795
Mailing Address - Country:US
Mailing Address - Phone:920-994-2000
Mailing Address - Fax:920-994-4953
Practice Address - Street 1:321 CARROLL STREET
Practice Address - Street 2:
Practice Address - City:RANDOM LAKE
Practice Address - State:WI
Practice Address - Zip Code:53075-1795
Practice Address - Country:US
Practice Address - Phone:920-994-2000
Practice Address - Fax:920-994-4953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4044012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty