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General NPI Number Information
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NPI Number | 1275814345
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Entity Type | Organization
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Legal Business Name | OPTIMAL PERFORMANCE HEALTH CARE CENTER LLC
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Dates
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Enumeration Date | 09/02/2011
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Last Update Date | 09/23/2011
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Provider Practice Location Address
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Address Line | 10500 W LOOMIS RD SUITE 160
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City | FRANKLIN
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State | WI
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Zip | 53132-8030
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Country | US
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Telephone | 414-491-8650
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Fax | 414-810-0894
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Provider Business Mailing Address
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Address Line | 1962 N COMMERCE ST
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City | MILWAUKEE
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State | WI
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Zip | 53212-3401
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Country | US
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Telephone | 414-491-8650
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Fax |
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Authorized Official
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Title or Position | OWNER/CLINIC DIRECTOR
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Name | DR. COREY VAN WESTEN
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Credential | D.C.
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Telephone | 414-491-8650
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | 4410-12
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License Number State | WI
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