=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003973868
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERSIDE CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 E MAIN ST LOWER
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53185-4302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-514-3600
-----------------------------------------------------
Fax | 262-514-3836
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 E MAIN ST LOWER
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53185-4302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-514-3600
-----------------------------------------------------
Fax | 262-514-3836
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER-MANAGER
-----------------------------------------------------
Name | DR. JENNY R GEIGER
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 26251436000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3469-012
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------