Provider Demographics
NPI:1184067894
Name:BELOIT CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:BELOIT CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:C
Authorized Official - Last Name:FENWICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-361-9000
Mailing Address - Street 1:1610 MADISON RD
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-3215
Mailing Address - Country:US
Mailing Address - Phone:608-361-9000
Mailing Address - Fax:
Practice Address - Street 1:1610 MADISON RD
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3215
Practice Address - Country:US
Practice Address - Phone:608-361-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
4163111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000035878Medicare PIN