MEDICARE: RUBERT CHIROPRACTIC CLINIC, S.C.

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	3728012	WI

General Provider Information

NPI Number	:	1215003892
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUBERT CHIROPRACTIC CLINIC, S.C.

Provider Business Mailing Address
First Line	:	PO BOX 325
Second Line	:
City	:	HUSTISFORD
State	:	WI
Zip	:	53034-0325
Country	:	US
Telephone Number	:	920-349-3233
Fax Number	:	920-349-3933

Provider Business Practice Location Address
First Line	:	139 N LAKE ST
Second Line	:
City	:	HUSTISFORD
State	:	WI
Zip	:	53034
Country	:	US
Telephone Number	:	920-349-3233
Fax Number	:	920-349-3933

Authorized Official
Title or Position	:	OWNER PRESIDENT
Name	:	DR. PAUL DAVID RUBERT
Credential	:	D.C.
Telephone Number	:	920-349-3233

Provider Enumeration Date	:	11/27/2006
Last Update Date	:	12/05/2007

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