Provider Demographics
NPI:1942358718
Name:VITALITY ENTERPRISES, LLC
Entity Type:Organization
Organization Name:VITALITY ENTERPRISES, LLC
Other - Org Name:WUSSOW CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WUSSOW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-833-1114
Mailing Address - Street 1:8434 OLD SAUK RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-4367
Mailing Address - Country:US
Mailing Address - Phone:608-833-1114
Mailing Address - Fax:
Practice Address - Street 1:8434 OLD SAUK RD
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-4367
Practice Address - Country:US
Practice Address - Phone:608-833-1114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000035554OtherMEDICARE PTAN