=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619214848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHIROPRACTIC & PHYSICAL THERAPY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2013
-----------------------------------------------------
Last Update Date | 01/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 577 BRAUND ST
-----------------------------------------------------
City | ONALASKA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54650-8556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-780-0559
-----------------------------------------------------
Fax | 608-781-8621
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 577 BRAUND ST
-----------------------------------------------------
City | ONALASKA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54650-8556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-780-0559
-----------------------------------------------------
Fax | 608-781-8621
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GARY FISCHER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 608-780-0559
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2406-012
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 3504-024
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------