Provider Demographics
NPI:1104804012
Name:BAY AREA CHIROPRACTIC SC
Entity type:Organization
Organization Name:BAY AREA CHIROPRACTIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:SERVAIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:920-468-1963
Mailing Address - Street 1:1441 BELLEVUE ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5605
Mailing Address - Country:US
Mailing Address - Phone:920-468-1963
Mailing Address - Fax:920-468-9785
Practice Address - Street 1:1441 BELLEVUE ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5605
Practice Address - Country:US
Practice Address - Phone:920-468-1963
Practice Address - Fax:920-468-9785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1783012111NN0400X
WI4055012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39001100Medicaid
WI39001100Medicaid
T63304Medicare UPIN