MEDICARE: BLACK RIVER CHIROPRACTIC CENTER, SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor		WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073514527
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK RIVER CHIROPRACTIC CENTER, SC

Provider Business Mailing Address
First Line	:	126 S 2ND ST
Second Line	:
City	:	BLACK RIVER FALLS
State	:	WI
Zip	:	54615-1726
Country	:	US
Telephone Number	:	715-284-2915
Fax Number	:	715-284-7492

Provider Business Practice Location Address
First Line	:	154 E 5TH ST
Second Line	:
City	:	NEILLSVILLE
State	:	WI
Zip	:	54456-1941
Country	:	US
Telephone Number	:	715-743-3404
Fax Number	:	715-743-4449

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RUTH V JEAN
Credential	:	DC DABCO
Telephone Number	:	715-284-2915

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	07/21/2022

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Directions to “BLACK RIVER CHIROPRACTIC CENTER, SC ” Practice Location

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