Provider Demographics
NPI:1902042922
Name:FOND DU LAC CHIROPRACTIC & WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:FOND DU LAC CHIROPRACTIC & WELLNESS CENTER LLC
Other - Org Name:IDEAL CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SERWE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-907-1700
Mailing Address - Street 1:976 E JOHNSON ST
Mailing Address - Street 2:STE 900
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-9746
Mailing Address - Country:US
Mailing Address - Phone:920-907-1700
Mailing Address - Fax:920-907-1708
Practice Address - Street 1:976 E JOHNSON ST
Practice Address - Street 2:STE 900
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-9746
Practice Address - Country:US
Practice Address - Phone:920-907-1700
Practice Address - Fax:920-907-1708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4174-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38185900Medicaid
WIWI1064Medicare PIN
WI38185900Medicaid