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General NPI Number Information
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NPI Number | 1720477540
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Entity Type | Organization
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Legal Business Name | NORTHSIDE CHIROPRACTIC CENTER LLC
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Dates
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Enumeration Date | 01/16/2015
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Last Update Date | 01/16/2015
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Provider Practice Location Address
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Address Line | 2337A JACKSON ST
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City | OSHKOSH
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State | WI
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Zip | 54901-1809
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Country | US
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Telephone | 920-573-0400
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Fax | 920-744-1442
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Provider Business Mailing Address
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Address Line | PO BOX 883
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City | OSHKOSH
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State | WI
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Zip | 54903-0883
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Country | US
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Telephone | 920-573-0400
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Fax | 920-744-1442
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | BRADLEY HUNTER
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Credential | D.C.
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Telephone | 920-573-0400
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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 | 4307-012
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License Number State | WI
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