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General NPI Number Information
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NPI Number | 1003054693
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Entity Type | Organization
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Legal Business Name | OCONOMOWOC CHIROPRACTIC
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Dates
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Enumeration Date | 02/04/2009
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Last Update Date | 11/06/2024
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Provider Practice Location Address
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Address Line | 880 SUMMIT AVE
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City | OCONOMOWOC
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State | WI
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Zip | 53066-3975
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Country | US
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Telephone | 262-567-4999
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Fax | 262-567-4699
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Provider Business Mailing Address
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Address Line | 880 SUMMIT AVE
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City | OCONOMOWOC
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State | WI
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Zip | 53066-3975
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Country | US
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Telephone | 262-567-4999
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Fax | 262-567-4699
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Authorized Official
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Title or Position | OWNER
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Name | DR. JEFF DANIEL RUTKOWSKI
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Credential | D.C.
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Telephone | 262-567-4999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 4325-012
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License Number State | WI
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