=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932392982
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LORENZ CHIROPRACTIC OFFICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2007
-----------------------------------------------------
Last Update Date | 05/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 W OAK ST
-----------------------------------------------------
City | BOSCOBEL
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53805-1519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-375-2411
-----------------------------------------------------
Fax | 608-375-2411
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 205
-----------------------------------------------------
City | BOSCOBEL
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53805-0205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-375-2411
-----------------------------------------------------
Fax | 608-375-2411
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CA
-----------------------------------------------------
Name | KARLA K COON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 608-375-2411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1898
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------