=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013197904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVER SHORES CHIROPRACTIC SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2007
-----------------------------------------------------
Last Update Date | 11/07/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 705 VILLAGE GREEN WAY SUITE 105
-----------------------------------------------------
City | WEST BEND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53090-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-334-4070
-----------------------------------------------------
Fax | 262-334-4078
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 705 VILLAGE GREEN WAY SUITE 105
-----------------------------------------------------
City | WEST BEND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53090-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-334-4070
-----------------------------------------------------
Fax | 262-334-4078
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIROPRACTOR
-----------------------------------------------------
Name | DR. KRYSTI K. WICK
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 262-573-4465
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4353-12
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------