Provider Demographics
NPI:1922299007
Name:PORT CHIROPRACTIC INC.
Entity Type:Organization
Organization Name:PORT CHIROPRACTIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:REIF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-268-7066
Mailing Address - Street 1:1000 N WISCONSIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1285
Mailing Address - Country:US
Mailing Address - Phone:262-284-7246
Mailing Address - Fax:
Practice Address - Street 1:1000 N WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1285
Practice Address - Country:US
Practice Address - Phone:262-284-7246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3605-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38923600Medicaid
WI70140Medicare PIN
WIU36668Medicare UPIN