=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235927930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELLSWORTH CHIROPRACTIC & WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2025
-----------------------------------------------------
Last Update Date | 04/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 187 E MAIN ST
-----------------------------------------------------
City | ELLSWORTH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54011-9188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-273-4115
-----------------------------------------------------
Fax | 715-273-6546
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 668
-----------------------------------------------------
City | ELLSWORTH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54011-0668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-273-4115
-----------------------------------------------------
Fax | 715-273-6546
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SAMANTHA K JOHNSON
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 715-273-4115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------