Healthcare Provider Details

I. General information

NPI: 1063494441
Provider Name (Legal Business Name): ROBERT DESUTTER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 11/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701C N RAILROAD ST
EAGLE RIVER WI
54521-8833
US

IV. Provider business mailing address

701C N RAILROAD ST PO BOX 851
EAGLE RIVER WI
54521-8833
US

V. Phone/Fax

Practice location:
  • Phone: 715-479-4214
  • Fax: 715-479-4214
Mailing address:
  • Phone: 715-479-4214
  • Fax: 715-479-4214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1641
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: