Provider Demographics
NPI:1013175314
Name:CHURCH CHIROPRACTIC CLINIC, LLC
Entity Type:Organization
Organization Name:CHURCH CHIROPRACTIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-754-6111
Mailing Address - Street 1:1515 MOUNT ZION AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-1111
Mailing Address - Country:US
Mailing Address - Phone:608-754-6111
Mailing Address - Fax:
Practice Address - Street 1:1515 MOUNT ZION AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-1111
Practice Address - Country:US
Practice Address - Phone:608-754-6111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1444012261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38755700Medicaid
WI38755700Medicaid
WIT61668Medicare UPIN