Provider Demographics
NPI:1679506711
Name:ANDERSON FAMILY CHIROPRACTIC SC
Entity Type:Organization
Organization Name:ANDERSON FAMILY CHIROPRACTIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-392-4883
Mailing Address - Street 1:2911 TOWER AVE
Mailing Address - Street 2:STE 4
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5322
Mailing Address - Country:US
Mailing Address - Phone:715-392-4883
Mailing Address - Fax:715-392-4873
Practice Address - Street 1:2911 TOWER AVE
Practice Address - Street 2:STE 4
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5322
Practice Address - Country:US
Practice Address - Phone:715-392-4883
Practice Address - Fax:715-392-4873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38872400Medicaid
WI000035871Medicare PIN