MEDICARE: CHIRO HEALTH CLINIC 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	4252	WI

General Provider Information

NPI Number	:	1215146840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIRO HEALTH CLINIC SC

Provider Business Mailing Address
First Line	:	122 S WASHINGTON ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54301-4211
Country	:	US
Telephone Number	:	920-435-7575
Fax Number	:	920-435-7574

Provider Business Practice Location Address
First Line	:	122 S WASHINGTON ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54301-4211
Country	:	US
Telephone Number	:	920-435-7575
Fax Number	:	920-435-7574

Authorized Official
Title or Position	:	OWNER SHAREHOLDER
Name	:	DR. JER LEE
Credential	:	D.C.
Telephone Number	:	920-435-7575

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	08/22/2020

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