Provider Demographics
NPI:1730463050
Name:PONICK CHIROPRACTIC
Entity Type:Organization
Organization Name:PONICK CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PONICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-644-5428
Mailing Address - Street 1:9520 COUNTY HIGHWAY H
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54768-6033
Mailing Address - Country:US
Mailing Address - Phone:715-644-5428
Mailing Address - Fax:715-644-5486
Practice Address - Street 1:9520 COUNTY HIGHWAY H
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:WI
Practice Address - Zip Code:54768-6033
Practice Address - Country:US
Practice Address - Phone:715-644-5428
Practice Address - Fax:715-644-5486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2802-12111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38861300Medicaid