Provider Demographics
NPI:1891912234
Name:SE WISCONSIN CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:SE WISCONSIN CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:WILSON
Authorized Official - Middle Name:N
Authorized Official - Last Name:MBURU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-664-1241
Mailing Address - Street 1:3843 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-3228
Mailing Address - Country:US
Mailing Address - Phone:262-664-1241
Mailing Address - Fax:
Practice Address - Street 1:3843 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-3228
Practice Address - Country:US
Practice Address - Phone:262-664-1241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2314-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty