=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447030853
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORNERSTONE CHIROPRACTIC OF ANTIGO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2023
-----------------------------------------------------
Last Update Date | 10/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2006 PROGRESS BLVD
-----------------------------------------------------
City | ANTIGO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54409-2475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-623-5481
-----------------------------------------------------
Fax | 715-627-0177
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2006 PROGRESS BLVD
-----------------------------------------------------
City | ANTIGO
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54409-2475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-623-5481
-----------------------------------------------------
Fax | 715-627-0177
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING AND COLLECTIONS COORDINATOR
-----------------------------------------------------
Name | MEGHAN PELLMANN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 715-623-5481
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------