Healthcare Provider Details

I. General information

NPI: 1932545621
Provider Name (Legal Business Name): AUGUSTA CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 E LINCOLN ST
AUGUSTA WI
54722-9234
US

IV. Provider business mailing address

112 E LINCOLN ST
AUGUSTA WI
54722-9234
US

V. Phone/Fax

Practice location:
  • Phone: 715-286-5515
  • Fax:
Mailing address:
  • Phone: 715-286-5515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3790-012
License Number StateWI

VIII. Authorized Official

Name: CHAD JOHNSON
Title or Position: MEMBER
Credential:
Phone: 715-286-5515