Healthcare Provider Details

I. General information

NPI: 1003151366
Provider Name (Legal Business Name): THE WELLNESS WAY APPLETON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W3169 VAN ROY RD STE #11
APPLETON WI
54915-3985
US

IV. Provider business mailing address

W3169 VAN ROY RD STE #11
APPLETON WI
54915-3985
US

V. Phone/Fax

Practice location:
  • Phone: 920-733-3371
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number3623-012
License Number StateWI

VIII. Authorized Official

Name: PATRICK M FLYNN
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 920-733-3371