MEDICARE: GOETZKE CHIROPRACTIC 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	3847-012	WI

General Provider Information

NPI Number	:	1174654024
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOETZKE CHIROPRACTIC INC.

Provider Business Mailing Address
First Line	:	1656 DORSET LN
Second Line	:	STE 400
City	:	NEW RICHMOND
State	:	WI
Zip	:	54017-2449
Country	:	US
Telephone Number	:	715-246-5600
Fax Number	:	715-246-5806

Provider Business Practice Location Address
First Line	:	1656 DORSET LN
Second Line	:	STE 400
City	:	NEW RICHMOND
State	:	WI
Zip	:	54017-2449
Country	:	US
Telephone Number	:	715-246-5600
Fax Number	:	715-246-5806

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LEO RAYMOND GONSOWSKI III
Credential	:	D.C.
Telephone Number	:	715-246-5600

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	08/13/2013

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