Provider Demographics
NPI:1245363043
Name:PLYMOUTH CHIROPRACTIC, SC
Entity type:Organization
Organization Name:PLYMOUTH CHIROPRACTIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CECKA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-892-8920
Mailing Address - Street 1:126 E MILL ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-1704
Mailing Address - Country:US
Mailing Address - Phone:920-892-8920
Mailing Address - Fax:920-892-8920
Practice Address - Street 1:126 E MILL ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-1704
Practice Address - Country:US
Practice Address - Phone:920-892-8920
Practice Address - Fax:920-892-8920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2629-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1235237603OtherPROVIDER NPI
WI124536Medicaid
WI000075195Medicare PIN