MEDICARE: WAUPACA CHIROPRACTIC CENTER, INC

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	3651	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	:	1124194790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAUPACA CHIROPRACTIC CENTER, INC

Provider Business Mailing Address
First Line	:	304 S WESTERN AVE
Second Line	:
City	:	WAUPACA
State	:	WI
Zip	:	54981-5703
Country	:	US
Telephone Number	:	715-258-8211
Fax Number	:

Provider Business Practice Location Address
First Line	:	304 S WESTERN AVE
Second Line	:
City	:	WAUPACA
State	:	WI
Zip	:	54981-5703
Country	:	US
Telephone Number	:	715-258-8211
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MIRIAM LEEAN-RODENZ
Credential	:	DC
Telephone Number	:	715-258-8211

Provider Enumeration Date	:	11/27/2006
Last Update Date	:	08/22/2020

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