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General NPI Number Information
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NPI Number | 1376922401
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Entity Type | Organization
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Legal Business Name | SUMMIT SPINE AND SPORT LLC
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Dates
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Enumeration Date | 05/21/2015
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Last Update Date | 05/21/2015
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Provider Practice Location Address
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Address Line | 616 S FARWELL ST
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City | EAU CLAIRE
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State | WI
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Zip | 54701-3828
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Country | US
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Telephone | 715-563-2201
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Fax |
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Provider Business Mailing Address
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Address Line | 627 GERMANIA ST
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City | EAU CLAIRE
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State | WI
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Zip | 54703-3147
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Country | US
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Telephone | 715-563-2201
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ELIZABETH GALLICK
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Credential | DC
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Telephone | 715-563-2201
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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 | 5074
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License Number State | WI
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