MEDICARE: BALANCE CHIROPRACTIC OF GREEN BAY, 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	4034012	WI

General Provider Information

NPI Number	:	1447483417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALANCE CHIROPRACTIC OF GREEN BAY, LLC

Provider Business Mailing Address
First Line	:	3221 VOYAGER DR
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-8349
Country	:	US
Telephone Number	:	920-664-0047
Fax Number	:	920-965-1059

Provider Business Practice Location Address
First Line	:	3221 VOYAGER DR
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-8349
Country	:	US
Telephone Number	:	920-664-0047
Fax Number	:	920-965-1059

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ANDREW DAVID KIEFERT
Credential	:	D.C.
Telephone Number	:	920-664-0047

Provider Enumeration Date	:	08/25/2009
Last Update Date	:	08/25/2009

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