Provider Demographics
NPI:1740670348
Name:CHERRYLAND CHIROPRACTIC AND REHABILITATION, LLC
Entity type:Organization
Organization Name:CHERRYLAND CHIROPRACTIC AND REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:GRENFELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-743-1000
Mailing Address - Street 1:810 S LANSING AVE STE A
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-2858
Mailing Address - Country:US
Mailing Address - Phone:920-743-1000
Mailing Address - Fax:
Practice Address - Street 1:810 S LANSING AVE STE A
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-2858
Practice Address - Country:US
Practice Address - Phone:920-743-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5045-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty