Provider Demographics
NPI:1750306957
Name:BOETTCHER, ERIC STEVEN (DC)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:STEVEN
Last Name:BOETTCHER
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:PO BOX 447
Mailing Address - Street 2:
Mailing Address - City:REDGRANITE
Mailing Address - State:WI
Mailing Address - Zip Code:54970-0447
Mailing Address - Country:US
Mailing Address - Phone:920-566-0767
Mailing Address - Fax:920-566-0769
Practice Address - Street 1:1100 E BANNERMAN AVE
Practice Address - Street 2:
Practice Address - City:REDGRANITE
Practice Address - State:WI
Practice Address - Zip Code:54970-9320
Practice Address - Country:US
Practice Address - Phone:920-566-0767
Practice Address - Fax:920-566-0769
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4106111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor