Provider Demographics
NPI:1760558191
Name:MOELLENDORF CHIROPRACTIC OFFICE, LTD.
Entity Type:Organization
Organization Name:MOELLENDORF CHIROPRACTIC OFFICE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:MOELLENDORF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-743-2126
Mailing Address - Street 1:1140 EGG HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1234
Mailing Address - Country:US
Mailing Address - Phone:920-743-2126
Mailing Address - Fax:920-743-1145
Practice Address - Street 1:1140 EGG HARBOR RD
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1234
Practice Address - Country:US
Practice Address - Phone:920-743-2126
Practice Address - Fax:920-743-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1869-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI75705Medicare UPIN
WIT62790Medicare ID - Type Unspecified