Provider Demographics
NPI:1790278695
Name:FOND DU LAC FAMILY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:FOND DU LAC FAMILY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPRENAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-872-2969
Mailing Address - Street 1:103 S PIONEER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3800
Mailing Address - Country:US
Mailing Address - Phone:920-872-2969
Mailing Address - Fax:
Practice Address - Street 1:103 S PIONEER RD STE 200
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-3800
Practice Address - Country:US
Practice Address - Phone:208-722-9639
Practice Address - Fax:920-933-2511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-14
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4745111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100014403Medicaid