Provider Demographics
NPI:1679249536
Name:LOOSEMORE, MILES M (DC)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:M
Last Name:LOOSEMORE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 COTTONWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-2016
Mailing Address - Country:US
Mailing Address - Phone:262-367-7424
Mailing Address - Fax:262-369-1068
Practice Address - Street 1:211 COTTONWOOD AVE
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-2016
Practice Address - Country:US
Practice Address - Phone:262-367-7424
Practice Address - Fax:262-369-1068
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5673-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor