=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417001140
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOSTRUP CHIROPRACTIC, S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2007
-----------------------------------------------------
Last Update Date | 03/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2827 RAPIDS DR
-----------------------------------------------------
City | RACINE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53404-1620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-633-3123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2827 RAPIDS DR
-----------------------------------------------------
City | RACINE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53404-1620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-633-3123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. IB THOSTRUP
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 262-633-3123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2351
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------