MEDICARE: DR. MARK WILLARD KREBSBACH D.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	3966012	WI

General Provider Information

NPI Number	:	1750375523
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK WILLARD KREBSBACH D.C.

Provider Business Mailing Address
First Line	:	2337 S RIDGE RD
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-5857
Country	:	US
Telephone Number	:	920-497-8378
Fax Number	:	920-498-8363

Provider Business Practice Location Address
First Line	:	2337 S RIDGE RD
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-5857
Country	:	US
Telephone Number	:	920-497-8378
Fax Number	:	920-498-8363

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	07/08/2007

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