MEDICARE: EAST SIDE CHIROPRACTIC AND LASER THERAPY CENTER 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	261Q00000X	Clinic/Center
2	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1508506353
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST SIDE CHIROPRACTIC AND LASER THERAPY CENTER LLC

Provider Business Mailing Address
First Line	:	1624 E MASON ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54302-2739
Country	:	US
Telephone Number	:	920-465-0400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1624 E MASON ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54302-2739
Country	:	US
Telephone Number	:	920-465-0400
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL ZASTROW
Credential	:	D.C.
Telephone Number	:	209-465-0400

Provider Enumeration Date	:	03/30/2022
Last Update Date	:	04/10/2025

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