Healthcare Provider Details

I. General information

NPI: 1700689395
Provider Name (Legal Business Name): POUA PHENG VUE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2025
Last Update Date: 03/29/2025
Certification Date: 03/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 ENTERPRISE DR
SHEBOYGAN WI
53083-2245
US

IV. Provider business mailing address

1412 SAINT CLAIR AVE
SHEBOYGAN WI
53081-3236
US

V. Phone/Fax

Practice location:
  • Phone: 924-459-9090
  • Fax:
Mailing address:
  • Phone: 920-254-7782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6300-12
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: