MEDICARE: WEST BEND 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	3501-012	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1780740308	OTHER	WI	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1336263078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST BEND CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	1305 CHESTNUT ST
Second Line	:	STE 3
City	:	WEST BEND
State	:	WI
Zip	:	53095-3007
Country	:	US
Telephone Number	:	262-335-4202
Fax Number	:	262-335-4223

Provider Business Practice Location Address
First Line	:	1305 CHESTNUT ST
Second Line	:	STE 3
City	:	WEST BEND
State	:	WI
Zip	:	53095-3007
Country	:	US
Telephone Number	:	262-335-4202
Fax Number	:	262-335-4223

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JENNI R. HAAK
Credential	:	D.C.
Telephone Number	:	262-335-4202

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	01/30/2012

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Directions to “WEST BEND CHIROPRACTIC, LLC ” Practice Location

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