=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336222645
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARSHALL TOLMAN LYSNE D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 10/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 CHRISTY ST.
-----------------------------------------------------
City | AMHERST
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-824-2121
-----------------------------------------------------
Fax | 715-824-2123
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 CHRISTY ST.
-----------------------------------------------------
City | AMHERST
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-824-2121
-----------------------------------------------------
Fax | 715-824-2123
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1281-012
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------