=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063961662
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENERQI, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2016
-----------------------------------------------------
Last Update Date | 09/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10827 W LINCOLN AVE
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53227-1127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-209-4228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10827 W LINCOLN AVE
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53227-1127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-209-4228
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | PROF. PAUL E SHINKLE
-----------------------------------------------------
Credential | LAC, MSOM
-----------------------------------------------------
Telephone | 414-209-4228
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 913-55
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------