Healthcare Provider Details

I. General information

NPI: 1851389167
Provider Name (Legal Business Name): LEO RAYMOND GONSOWSKI III DC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

471 S ARCH AVE
NEW RICHMOND WI
54017-1832
US

IV. Provider business mailing address

471 S ARCH AVE
NEW RICHMOND WI
54017-1832
US

V. Phone/Fax

Practice location:
  • Phone: 715-246-5600
  • Fax: 715-246-5806
Mailing address:
  • Phone: 715-246-5600
  • Fax: 715-246-5806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number3847-012
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: