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General NPI Number Information
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NPI Number | 1114335536
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Entity Type | Organization
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Legal Business Name | THE CENTER FOR COMPREHENSIVE CHIROPRACTIC CARE
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Dates
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Enumeration Date | 07/29/2014
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Last Update Date | 02/28/2019
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Provider Practice Location Address
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Address Line | 420 N CHESTNUT AVE SUITE B
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City | OCONTO FALLS
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State | WI
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Zip | 54154-1109
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Country | US
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Telephone | 920-848-2392
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Fax |
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Provider Business Mailing Address
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Address Line | 420 N CHESTNUT AVE SUITE B
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City | OCONTO FALLS
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State | WI
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Zip | 54154-1109
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Country | US
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Telephone | 920-848-2392
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR/OWNER
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Name | DR. JOSHUA DIETZE
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Credential | D.C.
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Telephone | 920-848-2392
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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 | 4951-12
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License Number State | WI
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