Healthcare Provider Details

I. General information

NPI: 1649327784
Provider Name (Legal Business Name): SCOTT M THEIRL D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 W GLEN OAKS LN SUITE 207
MEQUON WI
53092-3377
US

IV. Provider business mailing address

333 RIVERVIEW DR
THIENSVILLE WI
53092-1713
US

V. Phone/Fax

Practice location:
  • Phone: 800-385-1655
  • Fax:
Mailing address:
  • Phone: 800-385-1655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number#X009619
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number4227-012
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: