Provider Demographics
NPI:1881605111
Name:CALEDONIA CHIROPRACTIC CLINIC, SC
Entity type:Organization
Organization Name:CALEDONIA CHIROPRACTIC CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:P
Authorized Official - Last Name:SCHNEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-681-8829
Mailing Address - Street 1:5401 DOUGLAS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402
Mailing Address - Country:US
Mailing Address - Phone:262-681-8829
Mailing Address - Fax:262-681-8830
Practice Address - Street 1:5401 DOUGLAS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402
Practice Address - Country:US
Practice Address - Phone:262-681-8829
Practice Address - Fax:262-681-8830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3317-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39002000Medicaid
U61885Medicare UPIN
WI0001-35557Medicare ID - Type Unspecified