Provider Demographics
NPI:1922293711
Name:DORN FAMILY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:DORN FAMILY CHIROPRACTIC LLC
Other - Org Name:AXIS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBY
Authorized Official - Middle Name:C
Authorized Official - Last Name:DORN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-203-9036
Mailing Address - Street 1:1280 BROWN ST. STE K-2
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066
Mailing Address - Country:US
Mailing Address - Phone:262-203-9036
Mailing Address - Fax:262-203-9774
Practice Address - Street 1:1280 BROWN ST. STE K-2
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066
Practice Address - Country:US
Practice Address - Phone:262-203-9036
Practice Address - Fax:262-203-9774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4053-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI396984426007OtherBCBS
WI000068767Medicare UPIN
WI38958700Medicaid