Healthcare Provider Details

I. General information

NPI: 1275026650
Provider Name (Legal Business Name): HEGERFELD CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9749 KAHL ROAD
BLACK EARTH WI
53515
US

IV. Provider business mailing address

PO BOX 316
BLACK EARTH WI
53515-0316
US

V. Phone/Fax

Practice location:
  • Phone: 608-216-3206
  • Fax:
Mailing address:
  • Phone: 608-216-3206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2884-012
License Number StateWI

VIII. Authorized Official

Name: DR. VICKI L HEGERFELD
Title or Position: OWNER
Credential: DC
Phone: 608-216-3206