Provider Demographics
NPI:1780958637
Name:ADVANCED CHIROPRACTIC OF GREEN BAY LLC
Entity type:Organization
Organization Name:ADVANCED CHIROPRACTIC OF GREEN BAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PURSEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-434-7393
Mailing Address - Street 1:2149 VELP AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-5424
Mailing Address - Country:US
Mailing Address - Phone:920-434-7393
Mailing Address - Fax:920-434-7394
Practice Address - Street 1:2149 VELP AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-5424
Practice Address - Country:US
Practice Address - Phone:920-434-7393
Practice Address - Fax:920-434-7394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3102111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI388-78-200Medicaid
WI000035204Medicare UPIN