Provider Demographics
NPI:1003837170
Name:THE WELLNESS WAY GREEN BAY LLC
Entity type:Organization
Organization Name:THE WELLNESS WAY GREEN BAY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:M
Authorized Official - Last Name:FLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-429-2844
Mailing Address - Street 1:2525 W MASON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-4838
Mailing Address - Country:US
Mailing Address - Phone:920-429-2844
Mailing Address - Fax:920-429-2845
Practice Address - Street 1:2525 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4838
Practice Address - Country:US
Practice Address - Phone:920-429-2844
Practice Address - Fax:920-429-2845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3623012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100005820Medicaid
WI=========012OtherBLUE CROSS BLUE SHIELD
WI000035731Medicare PIN