Provider Demographics
NPI:1952625253
Name:COTTAGE GROVE FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:COTTAGE GROVE FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CHRISTIANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-839-5787
Mailing Address - Street 1:213 W COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9327
Mailing Address - Country:US
Mailing Address - Phone:608-839-5787
Mailing Address - Fax:
Practice Address - Street 1:213 W COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:WI
Practice Address - Zip Code:53527-9327
Practice Address - Country:US
Practice Address - Phone:608-839-5787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3224012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU55527Medicare UPIN
WI70946Medicare PIN