Provider Demographics
NPI:1659557510
Name:ELLSWORTH CHIROPRACTIC INC
Entity Type:Organization
Organization Name:ELLSWORTH CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:NISSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-273-4115
Mailing Address - Street 1:187 E MAIN ST
Mailing Address - Street 2:PO BOX 668
Mailing Address - City:ELLSWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:54011
Mailing Address - Country:US
Mailing Address - Phone:715-273-4115
Mailing Address - Fax:
Practice Address - Street 1:187 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:WI
Practice Address - Zip Code:54011
Practice Address - Country:US
Practice Address - Phone:715-273-4115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2462111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN64362ELOtherBLUE CROSS BLUE SHIELD
MN64362ELOtherBLUE CROSS BLUE SHIELD
WI=========010OtherBLUE CROSS BLUE SHIELD