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General NPI Number Information
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NPI Number | 1326452293
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Entity Type | Organization
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Legal Business Name | WISCONSIN FAMILY AND SPORTS CHIROPRACTIC, LLC
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Dates
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Enumeration Date | 06/18/2014
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Last Update Date | 12/30/2015
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Provider Practice Location Address
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Address Line | 10224 N PORT WASHINGTON RD SUITE F
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City | MEQUON
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State | WI
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Zip | 53092-5754
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Country | US
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Telephone | 262-236-9489
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Fax |
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Provider Business Mailing Address
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Address Line | 10224 N PORT WASHINGTON RD SUITE F
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City | MEQUON
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State | WI
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Zip | 53092-5754
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Country | US
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Telephone | 262-236-9489
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Fax |
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Authorized Official
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Title or Position | OWNER/DOCTOR
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Name | DR. MACKENZIE WOOD
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Credential | DC
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Telephone | 262-236-9489
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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 | 5018-12
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License Number State | WI
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