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General NPI Number Information
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NPI Number | 1386912954
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Entity Type | Organization
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Legal Business Name | WISCONSIN SPINAL REHABILITATION CENTER S.C.
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Dates
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Enumeration Date | 12/09/2011
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Last Update Date | 12/09/2011
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Provider Practice Location Address
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Address Line | 3224 W MAIN ST STE E
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City | EAST TROY
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State | WI
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Zip | 53120-1152
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Country | US
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Telephone | 262-642-4100
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Fax | 262-642-4101
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Provider Business Mailing Address
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Address Line | 3224 W MAIN ST STE E PO BOX 984
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City | EAST TROY
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State | WI
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Zip | 53120-1152
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Country | US
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Telephone | 262-642-4100
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Fax | 262-642-4101
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | PETER GORDON FRIEDRICHS
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Credential | DC
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Telephone | 262-642-4100
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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 | 3170
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License Number State | WI
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