Provider Demographics
NPI:1134172455
Name:WOLTER, CHAD CHARLES (DC)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:CHARLES
Last Name:WOLTER
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 1:2105 E CLAIREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-4768
Mailing Address - Country:US
Mailing Address - Phone:715-835-9405
Mailing Address - Fax:
Practice Address - Street 1:2105 E CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-4768
Practice Address - Country:US
Practice Address - Phone:715-835-9514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3151-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38921400Medicaid
WI38921400Medicaid
WIU50670Medicare UPIN