Healthcare Provider Details

I. General information

NPI: 1932411873
Provider Name (Legal Business Name): INSPIRING VITALITY WELLNESS INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 ENLOE ST SUITE 105
HUDSON WI
54016-8190
US

IV. Provider business mailing address

2920 ENLOE ST SUITE 105
HUDSON WI
54016-8190
US

V. Phone/Fax

Practice location:
  • Phone: 715-808-0716
  • Fax: 715-808-0807
Mailing address:
  • Phone: 715-808-0716
  • Fax: 715-808-0807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1664-012
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DARYL LEE COOPER
Title or Position: OWNER
Credential: DC
Phone: 715-808-0716