Healthcare Provider Details

I. General information

NPI: 1528302437
Provider Name (Legal Business Name): MEQUON CHIROPRACTIC OFFICE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10521 N PORT WASHINGTON RD
MEQUON WI
53092-5584
US

IV. Provider business mailing address

10521 N PORT WASHINGTON RD
MEQUON WI
53092-5584
US

V. Phone/Fax

Practice location:
  • Phone: 262-241-3434
  • Fax: 262-241-3903
Mailing address:
  • Phone: 262-241-3434
  • Fax: 262-241-3903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DEBRA BENNING
Title or Position: OFFICE MANAGER
Credential:
Phone: 262-241-3434