Provider Demographics
NPI:1013992627
Name:EIDEM, JOHN HENRY (DC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:HENRY
Last Name:EIDEM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:HORICON
Mailing Address - State:WI
Mailing Address - Zip Code:53032-1247
Mailing Address - Country:US
Mailing Address - Phone:920-485-4009
Mailing Address - Fax:920-485-0632
Practice Address - Street 1:514 E LAKE ST
Practice Address - Street 2:
Practice Address - City:HORICON
Practice Address - State:WI
Practice Address - Zip Code:53032-1247
Practice Address - Country:US
Practice Address - Phone:920-485-4009
Practice Address - Fax:920-485-0632
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2303012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38850600Medicaid
WI38850600Medicaid
U01303Medicare UPIN