=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295816700
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN CARL HURTGEN DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 W PRAIRIE VIEW RD SUITE 2
-----------------------------------------------------
City | CHIPPEWA FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54729-3639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-720-9097
-----------------------------------------------------
Fax | 715-720-6089
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3324 HOOVER AVE
-----------------------------------------------------
City | ALTOONA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54720-1028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-836-7648
-----------------------------------------------------
Fax | 715-720-6089
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 1667-012
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------