Healthcare Provider Details

I. General information

NPI: 1992243760
Provider Name (Legal Business Name): MICHAEL BOLLIG D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2017
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 E NORTH ST
DEFOREST WI
53532-1258
US

IV. Provider business mailing address

312 E NORTH ST
DEFOREST WI
53532-1258
US

V. Phone/Fax

Practice location:
  • Phone: 608-846-3337
  • Fax: 608-846-7033
Mailing address:
  • Phone: 608-846-3337
  • Fax: 608-846-7033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5250
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: