Healthcare Provider Details

I. General information

NPI: 1427361120
Provider Name (Legal Business Name): LACKMAN CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2010
Last Update Date: 07/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 RIB MOUNTAIN DR
WAUSAU WI
54401-7445
US

IV. Provider business mailing address

4001 RIB MOUNTAIN DR
WAUSAU WI
54401-7445
US

V. Phone/Fax

Practice location:
  • Phone: 715-571-2702
  • Fax:
Mailing address:
  • Phone: 715-571-2702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3393-012
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number3393-012
License Number StateWI

VIII. Authorized Official

Name: ZARA LACKMAN
Title or Position: CHIROPRACTOR, OWNER
Credential: D.C., D.I.C.C.P.
Phone: 715-571-2702