Healthcare Provider Details

I. General information

NPI: 1053319004
Provider Name (Legal Business Name): WADE DAVID SKOGMAN D.C.,C.S.C.S.,D.A.B.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 S MAIN ST
SEYMOUR WI
54165-1475
US

IV. Provider business mailing address

N8632 WOODLAND DR
SEYMOUR WI
54165-8875
US

V. Phone/Fax

Practice location:
  • Phone: 920-833-7844
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number3140
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: