Provider Demographics
NPI:1689906240
Name:HAZUKA SPINAL CENTER INC
Entity Type:Organization
Organization Name:HAZUKA SPINAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HAZUKA
Authorized Official - Suffix:
Authorized Official - Credentials:DACBSP
Authorized Official - Phone:920-468-4755
Mailing Address - Street 1:1742 E MASON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-3259
Mailing Address - Country:US
Mailing Address - Phone:920-468-4755
Mailing Address - Fax:920-468-4044
Practice Address - Street 1:1742 E MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-3259
Practice Address - Country:US
Practice Address - Phone:920-468-4755
Practice Address - Fax:920-468-4044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1340-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000075467OtherPTAN