Healthcare Provider Details

I. General information

NPI: 1295004992
Provider Name (Legal Business Name): CHIROPRACTIC NEUROLOGY CENTER OF GREEN BAY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2011
Last Update Date: 12/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 DEVELOPMENT DR SUITE 10
GREEN BAY WI
54311-4250
US

IV. Provider business mailing address

2625 DEVELOPMENT DR SUITE 10
GREEN BAY WI
54311-4250
US

V. Phone/Fax

Practice location:
  • Phone: 920-339-9581
  • Fax: 920-339-9340
Mailing address:
  • Phone: 920-339-9581
  • Fax: 920-339-9340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number3434
License Number StateWI

VIII. Authorized Official

Name: DR. SCOTT HAROLD WRUCK
Title or Position: OWNER
Credential: D.C.
Phone: 920-339-9581