Provider Demographics
NPI:1710072418
Name:BOELTE, STUART JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:STUART
Middle Name:JOHN
Last Name:BOELTE
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 1:1326 ROYALTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-1609
Mailing Address - Country:US
Mailing Address - Phone:715-258-8288
Mailing Address - Fax:715-258-7195
Practice Address - Street 1:1326 ROYALTON ST
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1609
Practice Address - Country:US
Practice Address - Phone:715-258-8288
Practice Address - Fax:715-258-7195
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3156012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38885800Medicaid
613541OtherACN
62411OtherMULTI PLAN
WI38885800Medicaid
U53263Medicare UPIN