Provider Demographics
NPI:1790903110
Name:BOSMA CHIROPRACTIC L.L.C.
Entity Type:Organization
Organization Name:BOSMA CHIROPRACTIC L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:BOSMA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-532-6450
Mailing Address - Street 1:450 HIGH ST.
Mailing Address - Street 2:STE 4
Mailing Address - City:WRIGHTSTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:54180
Mailing Address - Country:US
Mailing Address - Phone:920-532-6450
Mailing Address - Fax:920-532-6455
Practice Address - Street 1:450 HIGH ST.
Practice Address - Street 2:STE 4
Practice Address - City:WRIGHTSTOWN
Practice Address - State:WI
Practice Address - Zip Code:54180
Practice Address - Country:US
Practice Address - Phone:920-532-6450
Practice Address - Fax:920-532-6455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3807-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI389-36600Medicaid