MEDICARE: HEALTHSOURCE 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

General Provider Information

NPI Number	:	1528372604
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHSOURCE OF GREEN BAY LLC

Provider Business Mailing Address
First Line	:	106 S CHESTNUT AVE
Second Line	:
City	:	MARSHFIELD
State	:	WI
Zip	:	54449
Country	:	US
Telephone Number	:	715-384-9064
Fax Number	:	715-387-6954

Provider Business Practice Location Address
First Line	:	1743 EAST MASON ST
Second Line	:
City	:	GREENBAY
State	:	WI
Zip	:	54302-3251
Country	:	US
Telephone Number	:	920-486-4755
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARGARET MERTENS
Credential	:	DC
Telephone Number	:	715-384-9064

Provider Enumeration Date	:	08/02/2010
Last Update Date	:	08/02/2010

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Directions to “HEALTHSOURCE OF GREEN BAY LLC ” Practice Location

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