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General NPI Number Information
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NPI Number | 1568749976
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Entity Type | Organization
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Legal Business Name | CLEARWATER CHIROPRACTIC LLC
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Dates
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Enumeration Date | 11/14/2011
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Last Update Date | 11/14/2011
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Provider Practice Location Address
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Address Line | 2907 MALL DR
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City | EAU CLAIRE
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State | WI
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Zip | 54701-6866
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Country | US
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Telephone | 715-831-2111
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Fax | 715-831-2115
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Provider Business Mailing Address
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Address Line | 2907 MALL DR
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City | EAU CLAIRE
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State | WI
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Zip | 54701-6866
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Country | US
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Telephone | 715-831-2111
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Fax | 715-831-2115
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Authorized Official
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Title or Position | SHAREHOLDER
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Name | DAVID ROBERT FLOOD
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Credential | D,C.
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Telephone | 715-831-2111
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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 | 4229-012
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License Number State | WI
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