=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942591755
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ETERNAL SPRING NATURAL HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2011
-----------------------------------------------------
Last Update Date | 07/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 307 S COMMERCIAL ST SUITE 203
-----------------------------------------------------
City | NEENAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54956-5700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-486-1439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 307 S COMMERCIAL ST SUITE 203
-----------------------------------------------------
City | NEENAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54956-5700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-486-1439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TODD SHULFER
-----------------------------------------------------
Credential | D.C.,C.AC.
-----------------------------------------------------
Telephone | 920-486-1439
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3881-012
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------