Provider Demographics
NPI:1770644163
Name:MICHAEL CHIROPRACTIC CENTER SC
Entity Type:Organization
Organization Name:MICHAEL CHIROPRACTIC CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT MICHAEL CHIROPRACTIC CNTR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:CHIROPRACTOR
Authorized Official - Phone:262-785-1233
Mailing Address - Street 1:405 N CALHOUN RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005
Mailing Address - Country:US
Mailing Address - Phone:262-785-1233
Mailing Address - Fax:262-785-1258
Practice Address - Street 1:405 N CALHOUN RD
Practice Address - Street 2:SUITE 105
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005
Practice Address - Country:US
Practice Address - Phone:262-785-1233
Practice Address - Fax:262-785-1258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1918012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI606473100OtherDEPT LABOR
WI38838100Medicaid
WI402681OtherEMPL ID
WI38838100Medicaid
WI000062764Medicare ID - Type Unspecified
WI38838100Medicaid