=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972529352
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATERTOWN CHIROPRACTIC SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2006
-----------------------------------------------------
Last Update Date | 10/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615 E MAIN ST SUITE B
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53094-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-261-2204
-----------------------------------------------------
Fax | 920-261-3901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 615 E MAIN ST SUITE B
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53094-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-261-2204
-----------------------------------------------------
Fax | 920-261-3901
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT WATERTOWN CHIROPRACTIC
-----------------------------------------------------
Name | DR. JEFFREY C FRUENDT
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 920-261-2204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3037012
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------