Healthcare Provider Details

I. General information

NPI: 1730463050
Provider Name (Legal Business Name): PONICK CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9520 COUNTY HIGHWAY H
STANLEY WI
54768-6033
US

IV. Provider business mailing address

9520 COUNTY HIGHWAY H
STANLEY WI
54768-6033
US

V. Phone/Fax

Practice location:
  • Phone: 715-644-5428
  • Fax: 715-644-5486
Mailing address:
  • Phone: 715-644-5428
  • Fax: 715-644-5486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number2802-12
License Number StateWI

VIII. Authorized Official

Name: KIM PONICK
Title or Position: OFFICE MANAGER
Credential:
Phone: 715-644-5428