Healthcare Provider Details

I. General information

NPI: 1477683142
Provider Name (Legal Business Name): HORICON STREET CHIROPRACTIC, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 HORICON ST.
MAYVILLE WI
53050
US

IV. Provider business mailing address

935 HORICON STREET
MAYVILLE WI
53050
US

V. Phone/Fax

Practice location:
  • Phone: 920-387-3240
  • Fax: 920-387-4245
Mailing address:
  • Phone: 920-387-3240
  • Fax: 920-387-4245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2886-012
License Number StateWI

VIII. Authorized Official

Name: MRS. AMY B. MCDONDALD
Title or Position: CHIROPRACTIC ASSISTANT
Credential:
Phone: 920-387-3240