=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164010104
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN BAY CHIROPRACTIC CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2021
-----------------------------------------------------
Last Update Date | 01/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 S MILITARY AVE
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54303-2209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-490-0200
-----------------------------------------------------
Fax | 920-490-9698
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 S MILITARY AVE
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54303-2209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-490-0200
-----------------------------------------------------
Fax | 920-490-9698
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR/OWNER
-----------------------------------------------------
Name | DR. MAUREEN P O'CONNOR
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 920-490-0200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------