Provider Demographics
NPI:1649327784
Name:THEIRL, SCOTT M (DC)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:M
Last Name:THEIRL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1713
Mailing Address - Country:US
Mailing Address - Phone:800-385-1655
Mailing Address - Fax:
Practice Address - Street 1:1009 W GLEN OAKS LN
Practice Address - Street 2:SUITE 207
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3377
Practice Address - Country:US
Practice Address - Phone:800-385-1655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY#X009619111NN0400X
WI4227-012111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI1690OtherMEDICARE PTAN
NY#U79534Medicare UPIN
NY#U79534Medicare UPIN