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General NPI Number Information
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NPI Number | 1801076872
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Entity Type | Organization
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Legal Business Name | CREEKSIDE CHIROPRACTIC AND REHABILITATION, LTD.
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Dates
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Enumeration Date | 11/07/2007
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Last Update Date | 02/08/2024
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Provider Practice Location Address
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Address Line | 4000 ENTERPRISE DR
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City | SHEBOYGAN
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State | WI
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Zip | 53083-2245
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Country | US
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Telephone | 920-459-9090
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Fax | 920-459-7426
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Provider Business Mailing Address
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Address Line | 4000 ENTERPRISE DR
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City | SHEBOYGAN
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State | WI
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Zip | 53083-2245
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Country | US
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Telephone | 920-459-9090
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Fax | 920-459-7426
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | ANDREW L TISLAU
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Credential | DC
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Telephone | 920-459-9090
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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 | 4058-012
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 2308-12
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 4549-12
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License Number State | WI
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