MEDICARE: MIDWEST CHIROPRACTIC NEUROLOGY, 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

General Provider Information

NPI Number	:	1669037602
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST CHIROPRACTIC NEUROLOGY, LLC

Provider Business Mailing Address
First Line	:	2829 COUNTY HIGHWAY I # 3C
Second Line	:
City	:	CHIPPEWA FALLS
State	:	WI
Zip	:	54729-2652
Country	:	US
Telephone Number	:	470-334-4191
Fax Number	:

Provider Business Practice Location Address
First Line	:	2829 COUNTY HIGHWAY I # 3C
Second Line	:
City	:	CHIPPEWA FALLS
State	:	WI
Zip	:	54729-2652
Country	:	US
Telephone Number	:	470-334-4191
Fax Number	:

Authorized Official
Title or Position	:	CONTROLLING MEMBER
Name	:	DR. DREW DAVID GINTNER
Credential	:	DC
Telephone Number	:	470-334-4191

Provider Enumeration Date	:	05/06/2019
Last Update Date	:	05/06/2019

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