Provider Demographics
NPI:1942499520
Name:CHIRO-MED WEST TOWN SC
Entity Type:Organization
Organization Name:CHIRO-MED WEST TOWN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:W
Authorized Official - Last Name:BROCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-826-9090
Mailing Address - Street 1:6708 ODANA RD
Mailing Address - Street 2:STE B
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1066
Mailing Address - Country:US
Mailing Address - Phone:608-826-9090
Mailing Address - Fax:
Practice Address - Street 1:6708 ODANA RD
Practice Address - Street 2:STE B
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1066
Practice Address - Country:US
Practice Address - Phone:608-826-9090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2219111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38798900Medicaid
WI38798900Medicaid