Healthcare Provider Details

I. General information

NPI: 1902146160
Provider Name (Legal Business Name): BLACK EARTH CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2013
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9749 KAHL RD
BLACK EARTH WI
53515-9516
US

IV. Provider business mailing address

9749 KAHL RD
BLACK EARTH WI
53515-9516
US

V. Phone/Fax

Practice location:
  • Phone: 608-767-2226
  • Fax:
Mailing address:
  • Phone: 608-767-2226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number4130-012
License Number StateWI

VIII. Authorized Official

Name: DR. DUSTIN REESON
Title or Position: CHIROPRACTOR/OWNER
Credential: D.C.
Phone: 608-798-3437