Provider Demographics
NPI:1659709376
Name:BAYSIDE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:BAYSIDE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:CONNON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PIENCIKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-591-0141
Mailing Address - Street 1:1700 SAND ACRES DR STE 2A
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-7562
Mailing Address - Country:US
Mailing Address - Phone:920-591-0141
Mailing Address - Fax:
Practice Address - Street 1:1700 SAND ACRES DR STE 2A
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-7562
Practice Address - Country:US
Practice Address - Phone:920-591-0141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-15
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4214-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK100119441OtherPTAN
WIV09233Medicare UPIN