Healthcare Provider Details

I. General information

NPI: 1336222645
Provider Name (Legal Business Name): MARSHALL TOLMAN LYSNE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 10/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 CHRISTY ST.
AMHERST WI
54406
US

IV. Provider business mailing address

222 CHRISTY ST.
AMHERST WI
54406
US

V. Phone/Fax

Practice location:
  • Phone: 715-824-2121
  • Fax: 715-824-2123
Mailing address:
  • Phone: 715-824-2121
  • Fax: 715-824-2123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1281-012
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: