=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740329937
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHEBOYGAN CHIROPRACTIC PLUS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 01/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1028B INDIANA AVE
-----------------------------------------------------
City | SHEBOYGAN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53081-4913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-208-7000
-----------------------------------------------------
Fax | 920-457-6335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1028B INDIANA AVE
-----------------------------------------------------
City | SHEBOYGAN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53081-4913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-208-7000
-----------------------------------------------------
Fax | 920-208-7004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | AMY M ENDRU
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 920-208-7000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3638-012
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------