{
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"NPI": "1407946254",
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"ReplacementNPI": null,
"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "LAKE GENEVA CHIROPRACTIC PARTNERS",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
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"OtherOrgNameTypeCode": null,
"OtherLastName": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "612 S WELLS ST",
"SecondLineMailingAddress": "SUITE C",
"MailingAddressCityName": "LAKE GENEVA",
"MailingAddressStateName": "WI",
"MailingAddressPostalCode": "53147-2159",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "262-248-8177",
"MailingAddressFaxNumber": "262-248-6393",
"FirstLinePracticeLocationAddress": "612 S WELLS ST",
"SecondLinePracticeLocationAddress": "SUITE C",
"PracticeLocationAddressCityName": "LAKE GENEVA",
"PracticeLocationAddressStateName": "WI",
"PracticeLocationAddressPostalCode": "53147-2159",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "262-248-8177",
"PracticeLocationAddressFaxNumber": "262-248-6393",
"EnumerationDate": "10/13/2006",
"LastUpdateDate": "07/16/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BUNTROCK",
"AuthorizedOfficialFirstName": "JEFFREY",
"AuthorizedOfficialMiddleName": "GENE",
"AuthorizedOfficialTitle": "OWNER/DOCTOR",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DC",
"AuthorizedOfficialTelephoneNumber": "262-248-8177",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "111N00000X",
"TaxonomyName": "Chiropractor",
"LicenseNumber": "2834-012",
"LicenseNumberStateCode": "WI",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}