Provider Demographics
NPI:1881624823
Name:BUNTROCK, JEFFREY GENE (DC)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:GENE
Last Name:BUNTROCK
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 1:612 S WELLS ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2159
Mailing Address - Country:US
Mailing Address - Phone:262-248-8177
Mailing Address - Fax:262-248-6393
Practice Address - Street 1:612 S WELLS ST
Practice Address - Street 2:SUITE C
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2159
Practice Address - Country:US
Practice Address - Phone:262-248-8177
Practice Address - Fax:262-248-6393
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2834-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38863200Medicaid
WI000135180Medicare ID - Type UnspecifiedLAKE GENEVA CHIROPRACTIC