MEDICARE: RENEWED HEALTH FAMILY 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	111NX0100X	Occupational Health Chiropractor

General Provider Information

NPI Number	:	1215499397
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENEWED HEALTH FAMILY CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	N7004 COUNTY ROAD O
Second Line	:
City	:	ELKHORN
State	:	WI
Zip	:	53121-2827
Country	:	US
Telephone Number	:	262-903-1360
Fax Number	:

Provider Business Practice Location Address
First Line	:	16645 W GREENFIELD AVE STE D
Second Line	:
City	:	NEW BERLIN
State	:	WI
Zip	:	53151-1546
Country	:	US
Telephone Number	:	262-788-5940
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	EMILY JOHANNA JOHNSON
Credential	:	DC
Telephone Number	:	262-903-1360

Provider Enumeration Date	:	04/05/2019
Last Update Date	:	04/05/2019

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