=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255677340
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALEXANDER CHIROPRACTIC NEUROLOGY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2012
-----------------------------------------------------
Last Update Date | 06/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2717 18TH ST STE 100
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53140-4666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-484-4165
-----------------------------------------------------
Fax | 262-484-4326
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2717 18TH ST STE 100
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53140-4666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-484-4165
-----------------------------------------------------
Fax | 262-484-4326
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. KEITH ADAM ALEXANDER
-----------------------------------------------------
Credential | DC, DCBCN
-----------------------------------------------------
Telephone | 262-484-4165
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NN0400X
-----------------------------------------------------
Taxonomy Name | Neurology Chiropractor
-----------------------------------------------------
License Number | 4717-12
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------