MEDICARE: WAUPACA CHIROPRACTIC CENTER, INC.

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	2695	WI
2	111N00000X	Chiropractor	3651-012	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

General Provider Information

NPI Number	:	1609868793
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAUPACA CHIROPRACTIC CENTER, INC.

Provider Business Mailing Address
First Line	:	700 HILLCREST DR
Second Line	:
City	:	WAUPACA
State	:	WI
Zip	:	54981-1410
Country	:	US
Telephone Number	:	715-258-8211
Fax Number	:	715-258-0118

Provider Business Practice Location Address
First Line	:	700 HILLCREST DR
Second Line	:
City	:	WAUPACA
State	:	WI
Zip	:	54981-1410
Country	:	US
Telephone Number	:	715-258-8211
Fax Number	:	715-258-0118

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MIRIAM JOY LEEAN
Credential	:	D.C.
Telephone Number	:	715-258-8211

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	08/22/2020

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