Provider Demographics
NPI:1013932821
Name:SIMPLY CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:SIMPLY CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-233-1867
Mailing Address - Street 1:2303 SCHNEIDER AVE SE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-7005
Mailing Address - Country:US
Mailing Address - Phone:715-233-1867
Mailing Address - Fax:
Practice Address - Street 1:2303 SCHNEIDER AVE SE
Practice Address - Street 2:SUITE 150
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-7005
Practice Address - Country:US
Practice Address - Phone:715-233-1867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3763111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3763OtherSATE LICENSE