Provider Demographics
NPI:1184791717
Name:PROACTIVE CHIROPRACTIC S.C.
Entity type:Organization
Organization Name:PROACTIVE CHIROPRACTIC S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:W
Authorized Official - Last Name:LITWIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-734-7950
Mailing Address - Street 1:N162 EISENHOWER DR
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-6171
Mailing Address - Country:US
Mailing Address - Phone:920-734-7950
Mailing Address - Fax:920-734-7959
Practice Address - Street 1:N162 EISENHOWER DR
Practice Address - Street 2:SUITE 1200
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-6171
Practice Address - Country:US
Practice Address - Phone:920-734-7950
Practice Address - Fax:920-734-7959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3581-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000035834Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER