Healthcare Provider Details

I. General information

NPI: 1912121922
Provider Name (Legal Business Name): MORY VON WERNER CHIROPRACTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N MAIN ST
SEYMOUR WI
54165-1309
US

IV. Provider business mailing address

215 N MAIN ST
SEYMOUR WI
54165-1309
US

V. Phone/Fax

Practice location:
  • Phone: 920-833-7750
  • Fax:
Mailing address:
  • Phone: 920-833-7750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1888
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: