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General NPI Number Information
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NPI Number | 1891912234
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Entity Type | Organization
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Legal Business Name | SE WISCONSIN CHIROPRACTIC LLC
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 11/18/2014
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Provider Practice Location Address
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Address Line | 3843 DOUGLAS AVE
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City | RACINE
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State | WI
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Zip | 53402-3228
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Country | US
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Telephone | 262-664-1241
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Fax |
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Provider Business Mailing Address
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Address Line | 3843 DOUGLAS AVE
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City | RACINE
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State | WI
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Zip | 53402-3228
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Country | US
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Telephone | 262-664-1241
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | WILSON N MBURU
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Credential |
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Telephone | 262-664-1241
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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 | 2314-012
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License Number State | WI
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