=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427383157
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THRIVE CHIROPRACTIC AND WELLNESS CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2009
-----------------------------------------------------
Last Update Date | 05/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1052 OAK FOREST DR STE 210
-----------------------------------------------------
City | ONALASKA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54650-3427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-783-0384
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1052 OAK FOREST DR STE 210
-----------------------------------------------------
City | ONALASKA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54650-3706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-381-1208
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. AMBER TENILE PERGANDE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 253-381-1208
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4536-012
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------