Healthcare Provider Details

I. General information

NPI: 1356109623
Provider Name (Legal Business Name): ERIC BUSH DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 CENTENNIAL CENTRE BLVD STE 150
HOBART WI
54155-8918
US

IV. Provider business mailing address

3038 QUARRY PARK DR APT 9
DE PERE WI
54115-8350
US

V. Phone/Fax

Practice location:
  • Phone: 920-865-7225
  • Fax: 920-865-7224
Mailing address:
  • Phone: 608-558-4488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6175-12
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: