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General NPI Number Information
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NPI Number | 1346658903
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Entity Type | Organization
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Legal Business Name | WINNECONNE CHIROPRACTIC AND SPORTS REHAB LLC
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Dates
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Enumeration Date | 07/28/2014
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Last Update Date | 10/14/2014
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Provider Practice Location Address
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Address Line | 238 W MAIN STREET
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City | WINNECONNE
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State | WI
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Zip | 54986
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Country | US
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Telephone | 920-706-0178
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Fax | 920-706-0179
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Provider Business Mailing Address
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Address Line | PO BOX 365
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City | WINNECONNE
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State | WI
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Zip | 54986-0365
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Country | US
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Telephone | 920-706-0178
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Fax | 920-706-0179
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Authorized Official
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Title or Position | OWNER
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Name | DR. ALEXANDRA GRACE KELLOGG
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Credential | D.C
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Telephone | 920-915-4210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | 4667-012
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License Number State | WI
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