Provider Demographics
NPI:1972216166
Name:INNATE LIFE LLC
Entity Type:Organization
Organization Name:INNATE LIFE LLC
Other - Org Name:INNATE LIFE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILCAREK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-453-5365
Mailing Address - Street 1:PO BOX 351
Mailing Address - Street 2:
Mailing Address - City:TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54487-0351
Mailing Address - Country:US
Mailing Address - Phone:171-545-3536
Mailing Address - Fax:
Practice Address - Street 1:1338 N 4TH ST
Practice Address - Street 2:
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487-2137
Practice Address - Country:US
Practice Address - Phone:171-545-3536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-03
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1255868550Medicaid