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General NPI Number Information
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NPI Number | 1740518554
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Entity Type | Organization
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Legal Business Name | HAGEN CHIROPRACTIC, LTD.
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Dates
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Enumeration Date | 12/07/2009
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Last Update Date | 12/07/2009
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Provider Practice Location Address
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Address Line | 529 MILL ST
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City | GREEN LAKE
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State | WI
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Zip | 54941-9425
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Country | US
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Telephone | 920-294-4357
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 336
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City | GREEN LAKE
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State | WI
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Zip | 54941-0336
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Country | US
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Telephone | 920-294-4357
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ETHAN H HAGEN
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Credential | D.C.
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Telephone | 920-294-4357
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 4507-012
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License Number State | WI
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