Provider Demographics
NPI:1881230688
Name:FEDEWA, CALEB MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:CALEB
Middle Name:MICHAEL
Last Name:FEDEWA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 N CHESTNUT AVE STE B
Mailing Address - Street 2:
Mailing Address - City:OCONTO FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54154-1109
Mailing Address - Country:US
Mailing Address - Phone:920-848-2392
Mailing Address - Fax:920-239-8135
Practice Address - Street 1:420 N CHESTNUT AVE STE B
Practice Address - Street 2:
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1109
Practice Address - Country:US
Practice Address - Phone:920-848-2392
Practice Address - Fax:920-239-8135
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-27
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5546-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty