Healthcare Provider Details

I. General information

NPI: 1083772735
Provider Name (Legal Business Name): KETTLE MORAINE HEALTH CENTER, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 04/02/2023
Certification Date: 04/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 HILLSIDE DR STE A
DELAFIELD WI
53018-2165
US

IV. Provider business mailing address

2725 HILLSIDE DR STE A
DELAFIELD WI
53018-2165
US

V. Phone/Fax

Practice location:
  • Phone: 262-646-2123
  • Fax: 262-646-5615
Mailing address:
  • Phone: 262-646-2123
  • Fax: 262-646-5615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3384
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number33436
License Number StateWI

VIII. Authorized Official

Name: DR. RICHARD ALLEN VENSKE
Title or Position: OWNER/PROVIDER
Credential: DC
Phone: 262-646-2123