MEDICARE: GLENN R WYSOCKI DC

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	1512	WI
2	111NX0800X	Orthopedic Chiropractor	1512	WI

General Provider Information

NPI Number	:	1215064597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN R WYSOCKI DC

Provider Business Mailing Address
First Line	:	7537 22ND AVENUE
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53143-5701
Country	:	US
Telephone Number	:	262-652-3100
Fax Number	:	262-652-3100

Provider Business Practice Location Address
First Line	:	7537 22ND AVENUE
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53143-5701
Country	:	US
Telephone Number	:	262-652-3100
Fax Number	:	262-652-3100

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	12/09/2011

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Directions to “ GLENN R WYSOCKI DC” Practice Location

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