Healthcare Provider Details

I. General information

NPI: 1205104023
Provider Name (Legal Business Name): SPRING CREEK FAMILY CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2011
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 CORNER ST
LODI WI
53555-1109
US

IV. Provider business mailing address

602 CORNER ST
LODI WI
53555-1109
US

V. Phone/Fax

Practice location:
  • Phone: 608-592-2763
  • Fax:
Mailing address:
  • Phone: 608-592-2763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number4673-012
License Number StateWI

VIII. Authorized Official

Name: DR. MARCIA SCHAEFER
Title or Position: DOCTOR OF CHIROPRACTIC
Credential: DC
Phone: 608-592-2763