Provider Demographics
NPI:1780894709
Name:COLUMBUS CHIROPRACTIC CARE CENTER
Entity type:Organization
Organization Name:COLUMBUS CHIROPRACTIC CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:EDNA
Authorized Official - Last Name:RUPP
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-623-1106
Mailing Address - Street 1:146 W MILL ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-1585
Mailing Address - Country:US
Mailing Address - Phone:920-623-1106
Mailing Address - Fax:920-623-1107
Practice Address - Street 1:146 W MILL ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-1585
Practice Address - Country:US
Practice Address - Phone:920-623-1106
Practice Address - Fax:920-623-1107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3512-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39000400Medicaid
WIU71835Medicare UPIN
WI000035648Medicare ID - Type Unspecified