Provider Demographics
NPI:1689941601
Name:EAGLE RIVER CHIROPRACTIC SC
Entity Type:Organization
Organization Name:EAGLE RIVER CHIROPRACTIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MADDEROM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-479-8700
Mailing Address - Street 1:761 US HIGHWAY 45 S
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:WI
Mailing Address - Zip Code:54521-9110
Mailing Address - Country:US
Mailing Address - Phone:715-479-8700
Mailing Address - Fax:715-479-8799
Practice Address - Street 1:761 US HIGHWAY 45 S
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:WI
Practice Address - Zip Code:54521-9110
Practice Address - Country:US
Practice Address - Phone:715-479-8700
Practice Address - Fax:715-479-8799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4753012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty