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General NPI Number Information
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NPI Number | 1356492284
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Entity Type | Organization
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Legal Business Name | PEWAUKEE FAMILY CHIROPRACTIC SC
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Dates
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Enumeration Date | 01/16/2007
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Last Update Date | 05/13/2019
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Provider Practice Location Address
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Address Line | N28W23000 ROUNDY DR STE 101
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City | PEWAUKEE
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State | WI
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Zip | 53072-7300
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Country | US
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Telephone | 262-695-9206
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Fax |
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Provider Business Mailing Address
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Address Line | N28W23000 ROUNDY DR STE 101
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City | PEWAUKEE
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State | WI
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Zip | 53072-7300
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Country | US
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Telephone | 262-695-9206
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRADLEY CRISTOPHER PEARCE
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Credential |
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Telephone | 262-695-9206
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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 | 3904-012
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License Number State | WI
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