Provider Demographics
NPI:1689813545
Name:ST NICHOLAS HEALTH INSTITUTE SC
Entity Type:Organization
Organization Name:ST NICHOLAS HEALTH INSTITUTE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUNTIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:414-778-1455
Mailing Address - Street 1:1033 N MAYFAIR RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3442
Mailing Address - Country:US
Mailing Address - Phone:414-778-1455
Mailing Address - Fax:414-778-1865
Practice Address - Street 1:1033 N MAYFAIR RD
Practice Address - Street 2:SUITE 303
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3442
Practice Address - Country:US
Practice Address - Phone:414-778-1455
Practice Address - Fax:414-810-4052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-16
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3517-012111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU72492Medicare UPIN