Provider Demographics
NPI:1639351026
Name:IDEAL CHIROPRACTIC OF FOND DU LAC LLC
Entity type:Organization
Organization Name:IDEAL CHIROPRACTIC OF FOND DU LAC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-907-1700
Mailing Address - Street 1:976 E JOHNSON ST STE 900
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-9747
Mailing Address - Country:US
Mailing Address - Phone:920-907-1700
Mailing Address - Fax:920-907-1708
Practice Address - Street 1:976 E JOHNSON ST STE 900
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-9747
Practice Address - Country:US
Practice Address - Phone:920-907-1700
Practice Address - Fax:920-907-1708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4174-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1063589505OtherINDIVIDUAL NPI
WI1063589505OtherINDIVIDUAL NPI