Provider Demographics
NPI:1750375523
Name:KREBSBACH, MARK WILLARD (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLARD
Last Name:KREBSBACH
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 1:2337 S RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5857
Mailing Address - Country:US
Mailing Address - Phone:920-497-8378
Mailing Address - Fax:920-498-8363
Practice Address - Street 1:2337 S RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5857
Practice Address - Country:US
Practice Address - Phone:920-497-8378
Practice Address - Fax:920-498-8363
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3966012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIV03893Medicare UPIN