Healthcare Provider Details

I. General information

NPI: 1649225426
Provider Name (Legal Business Name): RADANDT CHIROPRACTIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 MEADOW LN SUITE D
PEWAUKEE WI
53072-5576
US

IV. Provider business mailing address

1840 MEADOW LN SUITE D
PEWAUKEE WI
53072-5576
US

V. Phone/Fax

Practice location:
  • Phone: 262-650-9337
  • Fax: 262-650-1659
Mailing address:
  • Phone: 262-650-9337
  • Fax: 262-650-1659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number2388
License Number StateWI

VIII. Authorized Official

Name: DR. BARRY MICHAEL RADANDT
Title or Position: OWNER
Credential: D.C.
Phone: 262-650-9337