Healthcare Provider Details

I. General information

NPI: 1356377519
Provider Name (Legal Business Name): BOSHOFF CHIROPRACTIC CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8812 W NORTH AVE
WAUWATOSA WI
53226-2726
US

IV. Provider business mailing address

906 REVERE DR
OCONOMOWOC WI
53066-4421
US

V. Phone/Fax

Practice location:
  • Phone: 414-774-2300
  • Fax: 414-774-0341
Mailing address:
  • Phone: 414-617-0909
  • Fax: 414-774-0341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3869-012
License Number StateWI

VIII. Authorized Official

Name: DR. LYNETTE BOSHOFF
Title or Position: OWNER
Credential: D.C.
Phone: 414-617-0909