Healthcare Provider Details

I. General information

NPI: 1548598352
Provider Name (Legal Business Name): WALWORTH COUNTY CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2009
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 PHOENIX ST
DELAVAN WI
53115-2340
US

IV. Provider business mailing address

517 CALDWELL AVE
OCONTO FALLS WI
54154-1139
US

V. Phone/Fax

Practice location:
  • Phone: 262-728-8208
  • Fax: 262-728-9818
Mailing address:
  • Phone: 920-846-3778
  • Fax: 920-846-3877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3043-012
License Number StateWI

VIII. Authorized Official

Name: DR. FRED D HELLER
Title or Position: PRESIDENT
Credential: D.C.
Phone: 920-604-1886