Healthcare Provider Details

I. General information

NPI: 1376689414
Provider Name (Legal Business Name): DCDO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19035 W CAPITOL DR SUITE 100
BROOKFIELD WI
53045-2755
US

IV. Provider business mailing address

19035 W CAPITOL DR SUITE 100
BROOKFIELD WI
53045-2755
US

V. Phone/Fax

Practice location:
  • Phone: 262-695-6744
  • Fax: 262-695-6466
Mailing address:
  • Phone: 262-695-6744
  • Fax: 262-695-6466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number4260-12
License Number StateWI

VIII. Authorized Official

Name: DR. SHANE M HUBER
Title or Position: PRESIDENT
Credential: DC
Phone: 262-695-6744