=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578618187
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRESS CHIROPRACTIC CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 11/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 A S. CENTER AVE.
-----------------------------------------------------
City | MERRILL
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-539-9797
-----------------------------------------------------
Fax | 715-539-9098
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109A S CENTER AVE
-----------------------------------------------------
City | MERRILL
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54452-1237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-539-9797
-----------------------------------------------------
Fax | 715-539-9098
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | KATHERINE M. GRESS-VOLPENTESTA
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 715-539-9797
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3550-012
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------