MEDICARE: WISCONSIN SPINAL REHABILITATION CENTER 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	3170	WI

General Provider Information

NPI Number	:	1386912954
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISCONSIN SPINAL REHABILITATION CENTER S.C.

Provider Business Mailing Address
First Line	:	3224 W MAIN ST STE E
Second Line	:	PO BOX 984
City	:	EAST TROY
State	:	WI
Zip	:	53120-1152
Country	:	US
Telephone Number	:	262-642-4100
Fax Number	:	262-642-4101

Provider Business Practice Location Address
First Line	:	3224 W MAIN ST STE E
Second Line	:
City	:	EAST TROY
State	:	WI
Zip	:	53120-1152
Country	:	US
Telephone Number	:	262-642-4100
Fax Number	:	262-642-4101

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	PETER GORDON FRIEDRICHS
Credential	:	DC
Telephone Number	:	262-642-4100

Provider Enumeration Date	:	12/09/2011
Last Update Date	:	12/09/2011

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