Provider Demographics
NPI:1689772485
Name:BAKKE, GREGG NELSON (DC)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:NELSON
Last Name:BAKKE
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 1:312 EAST NORTH STREET
Mailing Address - Street 2:BAKKE CHIROPRACTIC CLINIC SC
Mailing Address - City:DEFOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532
Mailing Address - Country:US
Mailing Address - Phone:608-846-3333
Mailing Address - Fax:608-846-7033
Practice Address - Street 1:312 EAST NORTH STREET
Practice Address - Street 2:BAKKE CHIROPRACTIC CLINIC SC
Practice Address - City:DEFOREST
Practice Address - State:WI
Practice Address - Zip Code:53532
Practice Address - Country:US
Practice Address - Phone:608-846-3333
Practice Address - Fax:608-846-7033
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1460012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391253374030OtherBLUE CROSS BLUE SHIELD
WI38759100Medicaid
WI38759100Medicaid