Healthcare Provider Details

I. General information

NPI: 1407053911
Provider Name (Legal Business Name): MAYVILLE CHIROPRACTIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S MAIN ST
MAYVILLE WI
53050-1641
US

IV. Provider business mailing address

1 S MAIN ST
MAYVILLE WI
53050-1641
US

V. Phone/Fax

Practice location:
  • Phone: 920-387-5995
  • Fax: 920-387-5887
Mailing address:
  • Phone: 920-387-5995
  • Fax: 920-387-5887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2075-012
License Number StateWI

VIII. Authorized Official

Name: DR. JOHN T RIEGLEMAN
Title or Position: DOCTOR OF CHIROPRACTIC
Credential: D.C.
Phone: 920-387-5995