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General NPI Number Information
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NPI Number | 1033281167
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Entity Type | Organization
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Legal Business Name | WIESZTORT FAMILY CHIROPRACTIC CLINIC, S.C.
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Dates
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Enumeration Date | 11/14/2006
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Last Update Date | 04/22/2008
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Provider Practice Location Address
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Address Line | 4014 77TH ST STE 2
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City | KENOSHA
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State | WI
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Zip | 53142-4314
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Country | US
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Telephone | 262-694-3530
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Fax | 262-925-8810
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Provider Business Mailing Address
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Address Line | 4014 77TH ST STE 2
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City | KENOSHA
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State | WI
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Zip | 53142-4314
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Country | US
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Telephone | 262-694-3530
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Fax | 262-925-8810
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. WALTER RUDOLPH WIESZTORT
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Credential | D.C.
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Telephone | 262-694-3530
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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 | 3514
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License Number State | WI
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