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General NPI Number Information
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NPI Number | 1336269661
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Entity Type | Organization
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Legal Business Name | LICKTEIG CHIROPRACTIC CLINIC,S.C.
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Dates
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Enumeration Date | 03/30/2007
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Last Update Date | 06/12/2013
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Provider Practice Location Address
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Address Line | 11649 N PORT WASHINGTON RD SUITE 100
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City | MEQUON
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State | WI
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Zip | 53092-3460
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Country | US
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Telephone | 262-240-2273
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Fax | 262-240-2260
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Provider Business Mailing Address
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Address Line | 11649 N PORT WASHINGTON RD SUITE 100
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City | MEQUON
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State | WI
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Zip | 53092-3460
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Country | US
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Telephone | 262-240-2273
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Fax | 262-240-2260
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Authorized Official
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Title or Position | OWNER
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Name | KARL ALBERT LICKTEIG
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Credential | D.C.
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Telephone | 262-240-2273
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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 | 2451-012
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License Number State | WI
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