Provider Demographics
NPI:1457751778
Name:ZASTROW CHIROPRACTIC OFFICE, LLC
Entity Type:Organization
Organization Name:ZASTROW CHIROPRACTIC OFFICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:ZASTROW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-465-0400
Mailing Address - Street 1:1624 E MASON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-2739
Mailing Address - Country:US
Mailing Address - Phone:920-465-0400
Mailing Address - Fax:920-465-1430
Practice Address - Street 1:1624 E MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-2739
Practice Address - Country:US
Practice Address - Phone:920-465-0400
Practice Address - Fax:920-465-1430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1813-12111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38777600Medicaid