Provider Demographics
NPI:1881826246
Name:RENEWED LIFE CHIROPRACTIC, S.C
Entity Type:Organization
Organization Name:RENEWED LIFE CHIROPRACTIC, S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DC
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-233-7750
Mailing Address - Street 1:720 HILL ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3539
Mailing Address - Country:US
Mailing Address - Phone:608-233-7750
Mailing Address - Fax:
Practice Address - Street 1:720 HILL ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3539
Practice Address - Country:US
Practice Address - Phone:608-233-7750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-19
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI621310Medicaid