Provider Demographics
NPI:1821636929
Name:WILD WILLOW NATURAL MEDICINE LLC
Entity Type:Organization
Organization Name:WILD WILLOW NATURAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MAY
Authorized Official - Last Name:DOTTO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-706-5668
Mailing Address - Street 1:W314N720 HIGHWAY 83
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-2900
Mailing Address - Country:US
Mailing Address - Phone:262-706-5668
Mailing Address - Fax:
Practice Address - Street 1:W314N720 HIGHWAY 83
Practice Address - Street 2:
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-2900
Practice Address - Country:US
Practice Address - Phone:262-706-5668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-19
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1215989165Medicaid