Provider Demographics
NPI:1972667913
Name:CHIROPRACTIC COMPANY S.C.
Entity Type:Organization
Organization Name:CHIROPRACTIC COMPANY S.C.
Other - Org Name:CHIROPRACTIC COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GERONDALE
Authorized Official - Suffix:
Authorized Official - Credentials:DC CC SP
Authorized Official - Phone:414-332-0859
Mailing Address - Street 1:5306 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4913
Mailing Address - Country:US
Mailing Address - Phone:414-332-0859
Mailing Address - Fax:414-332-3991
Practice Address - Street 1:5306 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4913
Practice Address - Country:US
Practice Address - Phone:414-332-0859
Practice Address - Fax:414-332-3991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38989100Medicaid