MEDICARE: BACK 2 ACTION CHIROPRACTIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	4946-12	WI

General Provider Information

NPI Number	:	1164889564
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK 2 ACTION CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	10533 W NATIONAL AVE
Second Line	:	STE 200
City	:	WEST ALLIS
State	:	WI
Zip	:	53227-2041
Country	:	US
Telephone Number	:	414-897-0971
Fax Number	:

Provider Business Practice Location Address
First Line	:	10533 W NATIONAL AVE
Second Line	:	STE 200
City	:	WEST ALLIS
State	:	WI
Zip	:	53227-2041
Country	:	US
Telephone Number	:	414-897-0971
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DOCTOR OF CHIROPRACTIC
Name	:	DR. STEVE C WILSENS
Credential	:	DC
Telephone Number	:	414-897-0971

Provider Enumeration Date	:	01/15/2016
Last Update Date	:	02/19/2016

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