Provider Demographics
NPI:1851447759
Name:DR LOOFBORO SC
Entity Type:Organization
Organization Name:DR LOOFBORO SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYLAND
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOOFBORO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:414-461-1055
Mailing Address - Street 1:11038 W CAPITAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222
Mailing Address - Country:US
Mailing Address - Phone:414-461-1055
Mailing Address - Fax:414-461-1337
Practice Address - Street 1:11038 W CAPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222
Practice Address - Country:US
Practice Address - Phone:414-461-1055
Practice Address - Fax:414-461-1337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1327111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
75166Medicare ID - Type Unspecified
T62626Medicare UPIN