Provider Demographics
NPI:1811929490
Name:QUALITY OF LIFE CHIROPRACTIC
Entity type:Organization
Organization Name:QUALITY OF LIFE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:GRENIER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-637-6767
Mailing Address - Street 1:729 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-1147
Mailing Address - Country:US
Mailing Address - Phone:608-637-6767
Mailing Address - Fax:608-637-3121
Practice Address - Street 1:729 N MAIN ST
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-1147
Practice Address - Country:US
Practice Address - Phone:608-637-6767
Practice Address - Fax:608-637-3121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2468012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38846800Medicaid