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General NPI Number Information
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NPI Number | 1285058966
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Entity Type | Organization
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Legal Business Name | RIVERSEDGE CHIROPRACTIC, LLC
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Dates
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Enumeration Date | 02/14/2014
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Last Update Date | 02/14/2014
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Provider Practice Location Address
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Address Line | 111 N MAIN ST SUITE 100
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City | JANESVILLE
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State | WI
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Zip | 53545-3096
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Country | US
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Telephone | 608-754-8977
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Fax | 608-754-8979
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Provider Business Mailing Address
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Address Line | 111 N MAIN ST SUITE 100
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City | JANESVILLE
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State | WI
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Zip | 53545-3096
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Country | US
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Telephone | 608-754-8977
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Fax | 608-754-8979
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Authorized Official
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Title or Position | OWNER/ CHIROPRACTOR
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Name | DR. ANDREW PAULL
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Credential | DC, CCSP
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Telephone | 608-754-8977
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | 4035-012
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License Number State | WI
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