Healthcare Provider Details

I. General information

NPI: 1013992627
Provider Name (Legal Business Name): JOHN HENRY EIDEM DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 E LAKE ST
HORICON WI
53032-1247
US

IV. Provider business mailing address

514 E LAKE ST
HORICON WI
53032-1247
US

V. Phone/Fax

Practice location:
  • Phone: 920-485-4009
  • Fax: 920-485-0632
Mailing address:
  • Phone: 920-485-4009
  • Fax: 920-485-0632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2303012
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: