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General NPI Number Information
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NPI Number | 1407007420
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Entity Type | Organization
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Legal Business Name | LAKE WISSOTA FAMILY CHIROPRACTIC
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Dates
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Enumeration Date | 10/08/2008
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Last Update Date | 01/14/2019
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Provider Practice Location Address
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Address Line | 107 N BRIDGE ST
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City | CHIPPEWA FALLS
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State | WI
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Zip | 54729-2404
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Country | US
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Telephone | 715-720-2887
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Fax |
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Provider Business Mailing Address
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Address Line | 107 N BRIDGE ST
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City | CHIPPEWA FALLS
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State | WI
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Zip | 54729-2404
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DOCTOR OF CHIROPRACTIC
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Name | DR. AMY GAMERDINGER JEFFERS
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Credential | D.C.
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Telephone | 715-720-2887
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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 | 4436-012
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License Number State | WI
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