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General NPI Number Information
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NPI Number | 1306197009
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Entity Type | Organization
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Legal Business Name | DYNAMIC CHIROPRACTIC, LTD
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Dates
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Enumeration Date | 09/21/2012
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Last Update Date | 10/15/2012
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Provider Practice Location Address
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Address Line | 858 HANSEN RD
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City | GREEN BAY
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State | WI
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Zip | 54304-5324
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Country | US
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Telephone | 920-321-2832
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Fax | 920-321-2834
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Provider Business Mailing Address
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Address Line | 858 HANSEN RD
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City | GREEN BAY
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State | WI
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Zip | 54304-5324
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Country | US
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Telephone | 920-321-2832
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Fax | 920-321-2834
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Authorized Official
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Title or Position | OWNER
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Name | DR. MATTHEW S THOMAS
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Credential | D.C.
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Telephone | 920-321-2832
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 4337-012
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License Number State | WI
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