=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174675466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVER VALLEY CHIROPRACTIC CENTER, SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 831 CRITTER CT STE 100
-----------------------------------------------------
City | ONALASKA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54650-8673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-781-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 831 CRITTER CT STE 100
-----------------------------------------------------
City | ONALASKA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54650-8673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-781-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOSHUA J POTARACKE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 608-781-2273
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4279
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------