Healthcare Provider Details

I. General information

NPI: 1144385873
Provider Name (Legal Business Name): CHIROPLUS COMPLIMENTARY HEALTH CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 05/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 LAKE STREET
GREEN LAKE WI
54941
US

IV. Provider business mailing address

PO BOX 458
GREEN LAKE WI
54941-0458
US

V. Phone/Fax

Practice location:
  • Phone: 920-294-3130
  • Fax: 920-294-3238
Mailing address:
  • Phone: 920-294-3130
  • Fax: 920-294-3238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3020
License Number StateWI

VIII. Authorized Official

Name: DR. COLLEEN POMPLUN
Title or Position: GENERAL PARTNER
Credential: DC
Phone: 920-294-3130