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General NPI Number Information
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NPI Number | 1093218745
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Entity Type | Organization
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Legal Business Name | TUNDRA CHIROPRACTIC, LLC
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Dates
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Enumeration Date | 03/08/2018
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 1251 SCHEURING RD
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City | DE PERE
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State | WI
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Zip | 54115-1003
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Country | US
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Telephone | 920-336-3353
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Fax |
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Provider Business Mailing Address
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Address Line | 2150 S COURTLAND DR
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City | GREEN BAY
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State | WI
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Zip | 54313-9360
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Country | US
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Telephone | 920-336-3353
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | KALLIE ANN MADISON
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Credential | DC
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Telephone | 920-336-3353
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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 | 5112-12
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 5115-12
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License Number State | WI
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