Healthcare Provider Details

I. General information

NPI: 1720169683
Provider Name (Legal Business Name): DEWANE D. FRASE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N9691 STATE HIGHWAY 13
PHILLIPS WI
54555-7771
US

IV. Provider business mailing address

N9691 STATE HIGHWAY 13
PHILLIPS WI
54555-7771
US

V. Phone/Fax

Practice location:
  • Phone: 715-339-2052
  • Fax: 715-339-2014
Mailing address:
  • Phone: 715-339-2052
  • Fax: 715-339-2014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3088-012
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: