Provider Demographics
NPI:1649454562
Name:STANLEY FAMILY CHIROPRACTIC LLC
Entity type:Organization
Organization Name:STANLEY FAMILY CHIROPRACTIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HAAS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-644-5677
Mailing Address - Street 1:123 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54768-1005
Mailing Address - Country:US
Mailing Address - Phone:715-644-5677
Mailing Address - Fax:715-644-3422
Practice Address - Street 1:123 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:WI
Practice Address - Zip Code:54768-1005
Practice Address - Country:US
Practice Address - Phone:715-644-5677
Practice Address - Fax:715-644-3422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1937 012111N00000X
WI4906-12111N00000X
WI48-70-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38785200Medicaid
WI100027384Medicaid
WI000170990Medicare PIN
WI38785200Medicaid