MEDICARE: WILDBERG CHIROPRACTIC OFFICE SC

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	1600-012	WI

General Provider Information

NPI Number	:	1558734251
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILDBERG CHIROPRACTIC OFFICE SC

Provider Business Mailing Address
First Line	:	811 W BROADWAY AVE
Second Line	:
City	:	MEDFORD
State	:	WI
Zip	:	54451-1307
Country	:	US
Telephone Number	:	715-748-2334
Fax Number	:	715-748-1124

Provider Business Practice Location Address
First Line	:	811 W BROADWAY AVE
Second Line	:
City	:	MEDFORD
State	:	WI
Zip	:	54451-1307
Country	:	US
Telephone Number	:	715-748-2334
Fax Number	:	715-748-1124

Authorized Official
Title or Position	:	OWNER
Name	:	BRADLEY WILDBERG
Credential	:	DC
Telephone Number	:	715-748-2334

Provider Enumeration Date	:	11/04/2015
Last Update Date	:	11/04/2015

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