Healthcare Provider Details

I. General information

NPI: 1295181774
Provider Name (Legal Business Name): GONZALEZ FAMILY CHIROPRACTIC LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 4TH AVENUE
WOODRUFF WI
54568-2061
US

IV. Provider business mailing address

1105 4TH AVENUE PO BOX 2061
WOODRUFF WI
54568-2061
US

V. Phone/Fax

Practice location:
  • Phone: 715-356-1606
  • Fax: 715-356-2170
Mailing address:
  • Phone: 715-356-1606
  • Fax: 715-356-2170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3390-12
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number3390-12
License Number StateWI

VIII. Authorized Official

Name: DR. GUILLERMO EDUARDO GONZALEZ
Title or Position: MEMBER/OWNER
Credential: D.C.
Phone: 715-356-1606