MEDICARE: GALLICK CHIROPRACTIC LLC

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	5073	WI

General Provider Information

NPI Number	:	1285162594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GALLICK CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	4753 COUNTY HIGHWAY J
Second Line	:
City	:	LAKE HALLIE
State	:	WI
Zip	:	54729-3387
Country	:	US
Telephone Number	:	720-448-5274
Fax Number	:

Provider Business Practice Location Address
First Line	:	4753 COUNTY HIGHWAY J
Second Line	:
City	:	LAKE HALLIE
State	:	WI
Zip	:	54729-3387
Country	:	US
Telephone Number	:	720-448-5274
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CLINIC DIRECTOR
Name	:	DR. SHANE GALLICK
Credential	:	DC
Telephone Number	:	720-448-5274

Provider Enumeration Date	:	05/31/2017
Last Update Date	:	07/21/2022

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