=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689906240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAZUKA SPINAL CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2010
-----------------------------------------------------
Last Update Date | 02/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1742 E MASON ST
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54302-3259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-468-4755
-----------------------------------------------------
Fax | 920-468-4044
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1742 E MASON ST
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54302-3259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-468-4755
-----------------------------------------------------
Fax | 920-468-4044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. MARTIN LEE HAZUKA
-----------------------------------------------------
Credential | DACBSP
-----------------------------------------------------
Telephone | 920-468-4755
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1340-12
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------