Provider Demographics
NPI:1336269661
Name:LICKTEIG CHIROPRACTIC CLINIC,S.C.
Entity Type:Organization
Organization Name:LICKTEIG CHIROPRACTIC CLINIC,S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARL
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:LICKTEIG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-240-2273
Mailing Address - Street 1:11649 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3460
Mailing Address - Country:US
Mailing Address - Phone:262-240-2273
Mailing Address - Fax:262-240-2260
Practice Address - Street 1:11649 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3460
Practice Address - Country:US
Practice Address - Phone:262-240-2273
Practice Address - Fax:262-240-2260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2451-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38854100Medicaid
WI38854100Medicaid
WI000135759Medicare ID - Type Unspecified