Provider Demographics
NPI:1952467995
Name:WELLNESS CHIROPRACTIC CENTER LLC
Entity Type:Organization
Organization Name:WELLNESS CHIROPRACTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BROTSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC DICCP
Authorized Official - Phone:920-262-0200
Mailing Address - Street 1:816 WEST ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-3601
Mailing Address - Country:US
Mailing Address - Phone:920-262-0200
Mailing Address - Fax:920-262-0210
Practice Address - Street 1:816 WEST ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-3608
Practice Address - Country:US
Practice Address - Phone:920-262-0200
Practice Address - Fax:920-262-0210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3025111N00000X
WI3149111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000235820OtherMEDICARE
WI000135820OtherMEDICARE
WI000135820OtherMEDICARE
U48953Medicare UPIN
WI000235820OtherMEDICARE